Ex  Libris 
C.  K.  OGDEN 


HEALTH   AND   DISEASE 

IN    RELATION    TO 

MARRIAGE  AND  THE  MARRIED  STATE 

A  Manual  Contributed  to  by 

Privatdozent  Dr.  med.  C.  ABELSDORFF,  Privatdozent  Dr.  med.  L.  BLUM- 
REICH,  Privatdozent  Dr.  phil.  R.  EBERSTADT,  Geh.  Med.-Rat  Prof.  Dr. 
A.  EULENBURC,  Geh.  Med.-Rat  Prof.  Dr.  C.  A.  EWALD,  Geh.  Med.-Rat  Prof. 
Dr.  P.  FURBRINGER,  Hofrat  Prof.  Dr.  med.  M.  CRUBER,  Dr.  med. 
W.  HAVELBURG,  Geh.  Med.-Rat  Prof.  Dr.  A.  HOFFA,  Prof.  Dr.  med.  et  phil. 
R.  KOSSMANN,  Geh.  Med.-Rat  Prof.  Dr.F.  KRAUS,  Dr.  med.  R.  LEDER- 
M  ANN,  Med.-Rat  Dr.  A.  LEPPM  ANN,  Geh.  Med.-Rat  Prof.  Dr.  E.  v.  LE  YDEN, 
Prof.  Dr.  Med.  E.  MENDEL,  Dr.  med.  A.  MOLL,  Geh.  Med.-Rat  Prof.  Dr. 
A.  NEISSER,  Geh.  Med.-Rat  Prof.  Dr.  J.  ORTH,  Dr.  med.  S.  PLACZEK, 
Prof.  Dr.  med.  et  phil.  C.  POSNER,  Privatdozent  Dr.  med.  P.  F.  RICHTER, 
Prof.  Dr.  med.  H.  ROSIN,  Dr.  med.  W.  WOLFF. 

Edited  by 

Geh.  Medizinalrat  Prof.  Dr.  H.  SENATOR 

and 

Dr.  med.  S.  KAMINER 

The  Only  Authorized  Translation  from  the 
German  into  the  English  Language  by 

J.  DULBERG,  M.D. 

of  Manchester,  England 

VOLUME  I. 


NEW    YORK 
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COPYRIGHT,  1904, 
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COPYRIGHT,  1904, 
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COPYRIGHT,  1904,  OF  THE  GERMAN  ORIGINAL  TEXT, 
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COPYRIGHT  IN  GERMANY,  1904,  OF  THE  GERMAN  ORIGINAL  TEXT, 
J.  F.  LEHMANN,  MUNICH,  BAVARIA. 


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NEW  YORK,  U.  S.  A. 


Annex 


Translator's   Preface. 

The  raison  d'etre  of  this  book  is  fully  explained  in  Pro- 
fessor Senator's  Introduction,  so  that  it  is  needless  for  me 
to  further  emphasize  it. 

I  have  endeavoured  to  render  a  faithful  version  of  the 
German  text  in  the  English  language.  Those  particularly 
who  are  acquainted  with  the  intricacies  of  the  German  tongue, 
especially  when  employed  in  writings  on  scientific  subjects,  will 
appreciate  the  onerous  task  I  have  undertaken  and  will  readily 
overlook  any  shortcomings  of  which  I  may  have  been  guilty. 

Although  much  contained  in  the  German  original  does 
not  seem  to  immediately  bear  upon  our  interests  here,  I  have 
thought  it  the  better  course  not  to  omit  any  portion,  and  I 
leave  it  to  the  judgment  of  the  reader  to  eliminate  what  he 
considers  superfluous. 

A  small  number  of  printer's  errors  have  crept  into  the 
text,  and  for  these  I  crave  the  indulgence  of  the  reader.  Atten- 
tion is  drawn  to  them  on  a  separate  page. 

JOSEPH  DULBERG,  M.D. 
Manchester,  July  6,  1904. 


CONTENTS. 


I.  INTRODUCTION    .    by  Geh.  Med.-Rat.  Prof.  Dr.  H.  Senator  (Berlin)        5 

II.  THE  HYGIENE  OF  MARRIAGE 

by  Hofrat  Prof.  Dr.  M.  Gruber  (Munich)      17 

III.  INHERITED    AND    CONGENITAL    DISEASES    AND    PREDISPOSITIONS    TO 

DISEASE     ...     by  Geh.  Med.-Rat.  Prof.  Dr.  J.  Orth  (Berlin)      37 

IV.  CONSANGUINITY  AND  MARRIAGE 

by  Geh.  Med.-Rat.  Prof.  Dr.  F.  Kraus  (Berlin)      79 

V.  THE  INFLUENCE  OF  CLIMATE,  RACE  AND  NATIONALITY  ON  MARRIAGE 

by  Dr.  med.  W.  Havelburg  (Berlin)     127 
VI.  SEXUAL  HYGIENE 

by  Geh.  Med.-Rat.  Prof.  Dr.  P.  Fiirbringer  (Berlin)    209 

VII.  MENSTRUATION,  PREGNANCY,  CHILD-BED  AND  LACTATION 

by  Prof.  Dr.  med.  et  phil.  R.  Kossmann  (Berlin)    245 

VIII.  CONSTITUTIONAL  DISEASES 

by  Geh.  Med.-Rat.  Prof.  Dr.  H.  Senator  (Berlin)    265 

IX.  DISEASES  OF  THE  BLOOD    .     .    by  Prof.  Dr.  med.  H.  Rosin  (Berlin)    295 

X.  DISEASES  OF  THE  VASCULAR  SYSTEM 

by  Geh.  Med.-Rat.  Prof.  Dr.  E.  v.  Leyden  (Berlin) 

and  Dr.  med.  W.  Wolf  (Berlin)    321 

XI.  DISEASES  OF  THE  RESPIRATORY  ORGANS 

by  Dr.  med.  S.  Kaminer  (Berlin)     363 

XII.  DISEASES  OF  THE  DIGESTIVE  ORGANS 

by  Geh.  Med.-Rat.  Prof.  Dr.  C.  A.  Ewald  (Berlin)    407 

XIII.  RENAL  DISEASES    .     by  Privatdoz.  Dr.  med.  P.  F.  Richter  (Berlin)    443 


LIST  OF  CONTENTS  OF  VOL.   II. 

(Subject  to  alteration.) 


XIV.  GONORRHCEAL  DISEASES         ....  by  Prof.  Dr.  A.  Neisser 

XV.  SYPHILIS .  .  by  R.  Ledermann,  M.D. 

XVI.  DISEASES  OF  THE  SKIN by  R.  Ledermann,  M.D. 

XVII.  DISEASES  OF  THE  ORGANS  OF  LOCOMOTION  .        by  Prof.  Dr.  A.  Hoffa 

XVIII.  CONGENITAL  AND  HEREDITARY  DISEASES  OF  THE  EYE 

By  G.  Abelsdorff,  M.D. 

XIX.  DISEASES  OF  THE  LOWER  URO-GENITAL  ORGANS,  AND  PHYSICAL  IMPOTENCE 

by  Prof.  Dr.  C.  Posner 

XX.  DISEASES  OF  WOMEN,  INCLUDING  STERILITY  .  by  L.  Blumreich,  M.D. 
XXI.  DISEASES  OF  THE  NERVOUS  SYSTEM  .  .  by  Prof.  Dr.  A.  Eulenburg 
XXII.  INSANITY by  Prof.  E.  Mendel 

XXIII.  PERVERSE  SEXUAL  SENSATIONS  AND  PSYCHICAL  IMPOTENCE, 

by  A.  Moll,  M.D. 

XXIV.  ALCOHOLIC  AND  OTHER  INTOXICATIONS,   INCLUDING  OCCUPATIONAL  DIS- 

EASES       by  A.  Leppmann,  M.D. 

XXV.  MEDICO-PROFESSIONAL  SECRECY    ....     by  S.  Placzek,  M.D. 

XXVI.  THE  ECONOMIC  IMPORTANCE  OF  SANITARY  CONDITIONS  IN  THE  MARRIED 
STATE by  R.  Eberstadt,  Ph.  D. 


I 

Introduction 


Health  and  Disease 

in  relation  to 

Marriage   and  the   Married  State 


Errata. 

(NOTE:  f.  i.  stands  for:  for  instance.) 

Page  54  line  26  for  to  regard  read  in  regard  to 

"  233  "  14  for  optical  read  optional 

"  246  "  6  for  tention  read  tension 

"  248  "  4  for  sensible  read  sensitive 

"  251  "  1 6  for  pregnancy  read  menstruation 

"  274  "  20  for  constituted  read  constitutes 

"  297  "  i  for  disappears  read  disappear 

"  303  "  26  for  froms  read  forms 

"  303  "  28  for  region  read  lesion 

"  423  "  II  for  light  read  high 

"  424  "  13  for  so  as  to  read  so  to 

"  425  "  14  for  1 8    days    after    read    18    cases    after 

"  431  "  13  for  appear  a  typical  read  appear  typical 

"  374  "  J4  for  probable  read  improbable 

"  391  "  1 6  for  physical  read  psychical 

11  445  "  10  for  %  read  °°/oo 

"  454  "  26  for  which  read  who 

"  476  "  30  for  appearances  read  appearance 


Health  and  Disease 

in  relation  to 

Marriage   and  the   Married  State 


INTRODUCTION 
By  Professor   H.  Senator  (Berlin) 

MARRIAGE  has  probably  at  all  times  and  with  all  nations — 
excepting  perhaps  a  few  races  in  the  lowest  stages  of  evolution 
— been  regarded  as  an  institution  of  the  highest  importance  to 
the  existence  and  prosperity  of  human  society.  The  marriage 
ceremony  has  consequently  always  been  celebrated  more  or  less 
solemnly  as  the  commencement  of  a  new  and  momentous  period 
and  distinguished  by  festivities  whose  nature  depended  upon  the 
actual  state  of  civilisation  as  an  exceedingly  great  event. 

From  very  early  times  religions  and  legislatures  have  endeav- 
oured by  laws  to  regulate  the  new  conditions  arising  from 
the  married  state  with  a  view  to  increasing  the  welfare  of  whole 
nations  or  of  the  entire  human  family.  Decisive  factors  in  the 
framing  of  those  laws  were  besides  the  demands  of  morality,  the 
judicial  aspects  of  marriage,  the  legal  relationship  between  hus- 
band and  wife,  that  between  them  and  their  relatives  and 
descendants  as  well  as  the  entire  community.  The  laws  as  to  mar- 
riage and  succession  have  been  drawn  up  by  all  civilised  States 
with  the  utmost  care  and  regard  to  minutest  details. 

On  the  other  hand  the  question  of  the  somatic  condition  in 
reference  to  marriage  and  the  marriage  contract  has  hitherto 
been  little  thought  of.  What  effect  the  physical  state  of  husband 
and  wife  has  upon  each  other  or  their  union;  vice-versa  what 
influence  marriage  has  upon  the  life  and  health  of  the  married 
couple  and  their  descendants  or  even  on  the  welfare  of  whole 
families  and  communities — these  questions  have  as  yet  received 
outside  medical  circles  and  particularly  at  the  hands  of  legisla- 


6  HEALTH,  DISEASE,  MARRIAGE 

tures  either  no  recognition  at  all  or  not  as  much  as  is  demanded 
by  our  present  knowledge  and  views. 

Even  the  Mosaic  law  which  contains  the  minutest  hygienic 
prescriptions  with  regard  to  every  phase  of  life  confines  itself 
on  this  subject  to  regulations  concerning  sexual  intercourse 
(particularly,  it  appears,  with  a  view  to  preventing  infection) 
and  to  that  connexion  which  is  designated  as  "Incest."  In  the 
law  books  of  other  nations  and  chiefly  those  of  the  civilised 
West  health  and  disease  with  regard  to  marriage  and  the  mar- 
ried state  are  only  taken  into  consideration  in  so  far  as  they 
affect  the  object  of  marriage.  As  such  was  exclusively 
looked  upon  in  olden  times  and  frequently  also  by  modern 
legislators1  the  procreation  of  children  for  the  propagation  and 
preservation  of  the  human  race  or  more  correctly,  as  the 
ancients  put  it,  for  the  continuity  and  advancement  of  the  State. 

As  a  result  of  this  point  of  view  the  absence  of  the  procrea- 
tive  age  and  any  physical  infirmity  impairing  the  procreative 
faculty  were  considered  valid  impediments  to  marriage;  other- 
wise no  importance  was  attached  to  the  physical  condition  of 
the  parties  contracting  or  living  in  marriage,  unless  such  a 
course  was  called  for  by  the  dictates  of  morality. 

The  intention  to  create  for  the  State  strong  and  hardy  citi- 
zens, and  only  such,  found  its  most  markedly  practical  expres- 
sion in  the  customs  of  the  Spartans  who  went  so  far  as  to 
suspend  compulsory  monogamy  or  monandry  in  the  case  of 
unfruitful  marriages  and  to  encourage  the  destruction  by  expos- 
ure of  delicate  and  sickly  infants.2  It  was  the  same  notion  that 
evidently  influenced  Plato3  when,  in  legislating  for  his  ideal 
State,  he  suggested  rules  and  regulations  as  to  the  contraction 
and  form  of  marriage,  which  intended  chiefly  for  full  citizens 
and  public  servants  had  no  other  object  in  view  but  the  pro- 
creation of  strong  and  active  children.  Aristotle*  went  even  to 
the  extreme  of  almost  demanding  the  municipalisation  of  mar- 
riage and  of  the  procreation  of  future  generations.  Those 
Spartan  customs  have  never  achieved  general  popularity,  and 


*For  instance,  the  Prussian  common-law  (Landrecht). 
*Xenophont  de  republ.  lacedaem.  I.  3  sq. 
'Plato,  de  republ.  V.,  chap.  8.  9. — Titn&us,  p.  193.  4. 
•Polit.  H.  3.  7-  IV.  B.,  14,  etc. 


INTRODUCTION  7 

they  are  indeed  diametrically  opposed  to  our  present-day 
feelings  and  our  conception  of  humanity  and  ethics.  The  views 
of  Plato  and  Aristotle  on  marriage  and  procreation  have  never 
been  put  to  a  practical  test,  not  in  ancient  times  and  still  less  at 
subsequent  periods,  partly  because  they  would  permit  to  the 
State  authorities  too  extraordinary  an  interference  with  the  per- 
sonal liberty  of  the  subject  and  partly  because  the  moral  essence 
of  matrimony  has  in  the  course  of  time  and  particularly  under 
the  influence  of  Christianity  come  into  greater  prominence. 
With  the  growing  authority  of  the  Church  the  solicitude  for 
the  spiritual  welfare  of  the  people  assumed  an  ever  increasing 
importance  and  all  other  considerations  especially  those  relating 
to  bodily  well-being,  earthly  possessions  and  physical  strength 
became  of  secondary  consequence.  Gradually,  however,  a 
change  took  place  and  the  physical  side  of  life  enjoys  at  the 
present  time  greater  appreciation  or  even  as  it  is  often 
reproached  with,  over-estimation.  Whether  this  reproach  is 
justified  or  not  the  endeavours  of  our  generation  to  raise  the 
prosperity  of  the  nations  by  politico-economic  measures  which 
have  many  points  in  common  with  various  sociological  ideas 
prevalent  in  olden  times  deserve  full  recognition. 

These  endeavours  and  measures  are  rightly  concerned  in  the 
first  instance  with  the  care  of  the  health  and  vigour  of  the 
community  which  are  necessary  conditions  of  spiritual  and  moral 
progress.  Mens  sana  in  corpore  sano.  From  this  standpoint  of 
public  health  and  the  preservation  of  the  national  energy  mar- 
riage deserves  the  fullest  consideration  much  more  than  it  has 
generally  received  hitherto,  because  its  importance  to  the  physi- 
cal and  mental  welfare  of  humanity  goes  further  than  the  desire 
for  a  healthy  and  vigorous  offspring.  Apart  from  the  sphere 
of  procreation  it  has  numerous  relations  to  health  and  disease, 
namely  in  three  directions.  Marriage  can  be  on  the  one  hand 
a  source  of  disease  or  the  aggravating  cause  of  pre-existent 
diseases;  vice-versa,  diseases  or  physical  defects  can  have  a  dis- 
turbing and  detrimental  influence  upon  marriage,  and  it  is  finally 
possible  for  marriage  to  consummate  the  cure  or  alleviation  of 
conditions  of  ill-health. 

With  regard  to  marriage  as  a  cause  of  disease  the  very 


8  HEALTH,  DISEASE,  MARRIAGE 

entrance  into  new  conditions  of  life  necessitated  by  the  act  of 
marriage,  the  separation  from  accustomed  surroundings,  the 
transition  to  an  intimate  companionship  with  a  person  of  the 
opposite  sex  can  give  rise  to  depressions  and  disturbances  of 
various  sorts.  These  may  be  caused  independently  of  sexual 
intercourse  by  the  necessity  of  husband  and  wife  to  fuse  their 
identities  and  by  the  mutual  dependence  upon  each  other  thus 
created — in  brief,  by  the  whole  force  of  the  new  mode  of  life. 

The  influence  of  marriage  in  this  connection  is  naturally 
stronger  and  more  frequently  evident  in  the  wife  than  the  hus- 
band, partly  because  of  the  greater  sensitiveness  of  the  nervous 
system  in  the  female  and  partly  because  the  changes  occasioned 
by  marriage  in  the  life  of  the  woman  are  of  much  vaster  signifi- 
cance than  is  the  case  with  the  man,  though  even  in  him  mar- 
riage, inasmuch  as  it  is  the  foundation  of  a  household  and  a 
family,  may  also  be  productive  of  diseases  as  an  outcome  of 
the  anxiety  and  worry  of  responsibility. 

Secondly  it  is  by  the  transmission  of  disease  from  one  person 
to  another  that  marriage  can  become  a  fruitful  source  of  ill- 
nesses not  only  of  a  venereal  character  but  also  of  other  kinds 
as  /.  ;.,  tuberculosis  and  other  infectious  or  parasitic  diseases; 
for  it  is  obvious  that  married  life  presents  the  most  favourable 
opportunity  to  all  the  causative  agents  of  an  infective  nature. 
Thirdly,  sexual  intercourse  per  se — that  is  where  both  hus- 
band and  wife  are  in  perfect  health  and  there  is  no  vestige  of 
any  transmissible  disease — can  produce  in  various  ways  condi- 
tions of  ill-health  either  of  a  purely  mechanical  nature  (as  f.  i. 
injuries,  haemorrhages  and  inflammations  caused  by  the  sexual 
act)  or  through  the  influence  which  this  act  exercises  upon  the 
nervous  system  and  which  again  is  keener  in  the  woman  than 
in  the  man,  or  finally  through  pregnancy  and  childbirth  which, 
although  physiological  processes,  are  nevertheless  often  enough 
the  starting  point  of  various  and  numerous  untoward  conditions. 

Fourthly  and  finally,  marriage  is  for  various  reasons  of  the 
highest  importance  as  to  the  life  and  health  of  the  offspring. 
To  begin  with,  the  labour  process  alone  may  cause  injury  to 
the  child  or  occasion  its  death.  But  of  no  less  import  arc  certain 
conditions  in  the  state  of  the  parents  or  of  one  of  them  prior  to 


INTRODUCTION  9 

the  birth  of  the  child  which  play  an  important  part  at  the 
conception  and  during  pregnancy  and  may  have  a  calamitous 
effect  upon  the  embryo.  Indeed  such  conditions  are  becoming 
too  frequent. 

It  is  erroneously  assumed  particularly  in  lay  circles  that  it 
is  only  for  such  diseases  of  their  parents  as  are  acquired  through 
debauchery  and  excesses  that  the  children  have  to  pay  the 
penalty.  This  is  not  so.  At  least  just  as  many  absolutely  innocent 
parents  free  from  all  taint  of  immorality  and  with  a  pure  past 
life  bring  into  the  world  dead  or  delicate  children,  chil- 
dren predisposed  to  all  kinds  of  diseases,  not  as  a  consequence 
of  their  sins  and  vices  but  through  circumstances  connected  with 
the  married  state  which  have  either  knowingly  or  unknowingly 
been  neglected  or  disregarded. 

As  sound  and  wholesome  fruit  can  only  grow  on  sound  soil 
so  a  healthy  vigorous  progeny  requires  health  and  vigour  in 
the  parents  and  ancestors.  This  radical  truth  has  from  the 
earliest  times  been  duly  appreciated  by  agriculturists  and  practi- 
cally acted  upon  with  regard  to  plants  and  animals.  It  is  true 
that  Plato1  has  recommended  a  similar  natural  selection  with 
regard  to  human  procreation  but  his  precepts,  though  they 
have  received  some  confirmation  by  the  Darwinian  theory,  have 
in  reality  remained  "platonic"  for  the  reasons  already  men- 
tioned. How  often  are  these  principles  violated  both  in  the 
contraction  of  marriages  and  in  their  consummation !  What  a 
number  of  weak  and  deteriorated  generations  have  been  the 
outcome  of  these  transgressions!  With  more  justification  than 
Mephistopheles  to  the  student  can  we  exclaim  to  every  child 
descended  from  diseased  ancestors,  to  every  descendant  of 
wretched  family  conditions:  "Woe  to  thee  that  thou  a  grand- 
son art!" 

And  vice-versa,  as  regards  the  influence  of  physical  defects 
or  of  disease  on  the  course  of  marriage  this  has  for  easily  com- 
prehensible reasons  never  been  misunderstood  or  undervalued 
since  it  at  once  affects  the  question  of  procreative  activity  or 
even  only  that  of  the  natural  gratification  of  the  sexual  instinct. 
As  has  already  been  mentioned,  both  in  ancient  times  as  well 


'De  republ.  VIII.  459. 


io  HEALTH,  DISEASE,  MARRIAGE 

as  at  subsequent  periods  regulations  have  been  decreed  by  the 
State  or  the  Church  with  a  view  to  preventing  marriages  incom- 
patible with  those  objects  or  to  dissolving  them  when  they  had 
already  been  contracted.  These  regulations  of  the  different  legis- 
latures though  unequal  in  their  extent  were  unanimous  in  taking 
into  consideration  only  a  very  small  number  of  the  physical 
conditions  which  can  have  a  disturbing  or  damaging  effect  upon 
the  married  state.  The  reason  is  that  the  essence  of  marriage 
does  not  consist  exclusively  of  the  above-named  objects  relating 
merely  to  sexual  life,  and  because  all  those  disturbances  which 
do  not  refer  to  the  latter  have  either  been  entirely  disregarded 
or  very  little  thought  of.  It  also  became  necessary  with  the 
gradually  rising  conception  of  the  essence  of  marriage  to  attach 
proportionately  less  importance  to  bodily  defects  and  infirmi- 
ties. Moreover  the  view  which  the  Church  took  of  marriage 
as  a  divine  institution  or  a  sacrament  was  necessarily  followed 
by  as  limited  a  restriction  as  possible  of  the  impediments  to 
marriage.  The  consideration  which  also  has  to  be  paid  to  per- 
sonal liberty,  to  the  right  of  the  individual  to  choose  for 
himself,  a  right  which  on  such  occasions  as  the  contraction  and 
consummation  of  marriage  is  of  greater  importance  than  in  any 
other  human  institution,  seems  to  make  it  very  desirable  that  the 
marriage  laws  should  contain  as  few  ordinances  as  possible. 

It  is  not  the  province  of  the  medical  man  to  lay  down  any 
rules  because  from  the  purely  medical  point  of  view  it  is  only 
necessary  to  establish  the  fact  that  just  as  it  may  occasion  dan- 
ger to  health,  so  marriage  may  on  the  other  hand  itself  be 
subject  to  danger  either  through  disease  or  through  imperfect 
physical  development,  and  that  this  danger  is  present  not  only 
under  circumstances  connected  in  any  way  with  sexual  life  but 
also  in  other  deviations  from  health  and  normality. 

It  is  absolutely  clear  that  it  is  principally,  if  not  exclusively, 
chronic  and  hardly  ever  acute  conditions  which  can  act  injuri- 
ously upon  marriage.  There  will  be  opportunities  to  enter  more 
minutely  into  this  part  of  the  subject  when  discussing  the  several 
diseases  in  their  relation  to  married  life.  But  these  same  rela- 
tions present  finally  also  a  more  agreeable  side  inasmuch  as 
marriage  can  and  often  does  exercise  also  a  beneficial,  salutary 


INTRODUCTION  n 

influence  upon  the  life  and  health  of  husband  or  wife.  This 
influence  can  make  itself  felt  prophylactically  as  well  as  thera- 
peutically.  Prophylactically  in  so  far  as  married  life  with  its 
attendant  regular  habits  presents  fewer  opportunities  for 
debauchery  or  other  insalutary  transgressions  and  more  favour- 
able hygienic  conditions  than  single  life,  particularly  so  in  the 
case  of  bachelors;  and  therapeutically  inasmuch  as  there  are 
conditions  of  ill-health  which  undoubtedly  benefit  or  are  even 
cured  by  the  matrimonial  state.  They  are  mostly  conditions  of 
the  nervous  system,  of  the  sexual  life,  and  certain  anomalies  of 
the  pelvic  organs  and  of  the  blood  more  or  less  intimately  con- 
nected with  the  procreative  faculty.  This  therapeutical  effect  of 
marriage  is  also  of  deeper  importance  to  the  female  sex  than  to 
the  male  and  though  it  may  not  play  as  weighty  a  part  as  the 
stiological  factor  of  marriage  does  in  the  causation  of  disease 
it  is  not  by  any  means  deserving  of  undervaluation. 


The  foregoing  remarks  should  make  it  sufficiently  clear  that 
matrimony  with  all  its  consequential  conditions  presents  an  enor- 
mous field  to  the  activity  of  Public  Hygiene  and  of  Preventive 
Medicine.  We  have  only  to  think  of  the  number  of  marriages 
which  are  constantly  being  entered  into  without  any  regard  to 
the  physical  condition  of  the  parties  contracting  them,  without 
any  attention  being  paid  to  their  constitution,  state  of  health, 
descent  or  possible  hereditary  predisposition  to  disease.  Let  us 
realise  how  often  necessary  sanitary  precautions  are  through 
ignorance  or  carelessness,  or  for  the  sake  of  other  considerations, 
neglected  by  people  about  to  marry  or  already  married,  and 
we  shall  at  once  understand  how  it  is  that  marriage  is  responsi- 
ble for  so  much  disease  and  misery,  so  much  wretchedness  and 
misfortune  in  this  world,  and  also  how  much  of  it  could  be 
avoided  by  judicious  sanitary  measures.  Truly  an  object  worth 
striving  for! 

In  order  to  attain  it,  it  is  above  all  necessary  that  the  medical 
profession  should  become  familiar  with  all  the  conditions  bear- 
ing on  the  subject  and  that  it  should  be  consulted  before  the 
consummation  of  intended  marriages  as  well  as  during  married 
life.  There  is  no  more  appropriate  person  for  this  than  the 


12  HEALTH,  DISEASE,  MARRIAGE 

ordinary  family  practitioner  who  knows  the  histories  of  the 
patients  entrusted  to  his  care  and  therefore  has  unequalled 
opportunities  of  observing  them  from  their  childhood  or  even 
from  their  birth.  It  is  to  be  regretted  that  the  tendency  among 
the  public  to  consult  a  specialist  in  every  case  of  illness  is  having 
the  effect  of  gradually  eliminating  the  old-fashioned  family 
attendant,  a  class  of  practitioners  who  should  rather  receive  all 
possible  encouragement  with  a  view  to  becoming  much  more 
general.  To  decide  whether  a  specialist  is  required  or  n6t, 
ought  to  be  the  concern  of  the  family  doctor  who,  no  matter 
how  capable  he  is,  cannot  be  expected  to  be — nor  is  it  necessary 
that  he  should — an  expert  in  every  branch  of  medicine,  but 
is  certainly  more  qualified  than  a  layman  to  judge  whether  the 
opinion  of  any  particular  authority  is  called  for. 

In  like  manner  this  applies  to  the  problems  with  regard  to 
marriage  and  the  contraction  of  marriage  which  we  should  like 
to  see  assigned  to  the  medical  man.  For  the  questions  relating 
to  this  matter  belong  to  the  various  domains  of  medicine ;  they 
are  consequently  found  more  or  less  scattered  among  the  sub- 
jects dealt  with  by  its  several  subdivisions,  though  not  always 
exactly  from  those  points  of  view  which  interest  us  here.  Some 
of  these  questions  indeed  have  only  arisen  within  recent  times 
and  been  made  the  object  of  special  research;  others  again 
though  not  exactly  new  yet  have  only  lately  been  elaborated 
more  carefully  than  was  possible  in  former  times.  May  it  suffice 
to  merely  mention  here  the  theory  of  parasitic  diseases  and  their 
transmission,  the  doctrine  of  heredity  and  hereditary  predis- 
position. 

There  appears  consequently  to  be  every  justification  for  the 
attempt  made  as  far  as  I  know  for  the  first  time  by  the  present 
Manual  to  collect  all  these  questions  into  a  comprehensible 
ensemble  that  shall  serve  to  the  medical  man  as  a  source  of 
information,  as  a  guide  to  his  conduct  in  circumstances  affecting 
the  weal  and  woe  of  so  many  human  beings.  For  may  not  the 
dictum  of  the  physician  have  a  decisive  influence  upon  the 
future  of  whole  generations? 

Of  course  it  will  often  be  extremely  difficult,  sometimes  per- 
haps impossible,  to  arrive  at  a  decision,  for  even  medical  skill 


INTRODUCTION  13 

and  knowledge  cannot  accomplish  the  superhuman;  but  this 
book  will  ever  act  as  a  help  and  counsellor  to  the  practitioner 
by  informing  him  to  what  extent  medical  interference  is 
possible.  In  doubtful  cases  it  is  better  to  declare  oneself 
incompetent  rather  than  shoulder  unlimited  responsibility  by  a 
decisive  opinion. 

It  is  not  unreasonable  to  hope  that  when  the  knowledge  of 
the  relations  between  marriage  on  the  one  hand  and  health  and 
disease  on  the  other  will  have  become  more  general  in  medical 
circles  the  profession  will  by  its  exertions,  by  instruction,  expla- 
nations and  warnings  succeed  in  convincing  the  larger  public  as 
to  the  utility,  aye,  necessity  of  taking  into  consideration  the 
physical  condition  of  the  parties  contracting  or  living  in  mar- 
riage. Is  a  medical  opinion  less  called  for  on  such  occasions 
than  it  is  for  instance  with  respect  to  the  fitness  of  school- 
children, the  inspection  of  scholastic  establishments  or  the 
acceptance  of  candidates  for  life  insurance? 

It  can  hardly  be  expected  or  demanded  that  this  conviction 
shall  result  in  submission  to  medical  authority  in  absolutely 
every  case.  There  may  arise  occasions  when  considerations  of 
health  or  even  life  would  have  to  yield  to  others  far  more 
weighty  and  when  medical  opinion  would  be  obliged  to  give 
way  to  circumstances  of  superior  force. 

It  were  also  desirable  that  the  State  or  Municipalities  should 
devote  greater  attention  than  has  hitherto  been  the  case  to  the 
somatic  conditions  of  persons  about  to  marry  or  already  mar- 
ried without  giving  rise  to  any  fears  that  compulsory  measures 
will  become  an  immediate  necessity.  But  inasmuch  as  marriage 
is  an  institution  of  the  deepest  importance  to  the  welfare  and 
economical  prosperity  of  a  nation  the  query  is  by  no  means 
unjustified  whether  it  ought  not  to  be  permissible  in  the  inter- 
ests of  the  commonwealth  to  introduce  measures  calculated  to 
restrict  marriage  where  the  sanitary  conditions  are  unsatis- 
factory or  to  protect  from  danger  persons  already  married 
much  in  the  same  way  as  is  done  by  the  laws  and  regulations 
with  regard  to  vaccination,  disinfection,  etc.  The  question  may 
therefore  well  be  asked  whether  having  regard  to  the  health  of 
the  people  living  in  matrimony  and  to  that  of  their  descendants 


i4  HEALTH,  DISEASE,  MARRIAGE 

there  should  not  be  an  expansion  of  the  legal  impediments  to 
marriage  and  of  the  divorce  laws  as  also  of  the  punishable 
offences  committed  by  husband  or  wife  against  each  other  or 
their  offspring.  At  the  same  time  it  must  be  admitted  that  the 
difficulties  which  will  have  to  be  overcome  in  order  to  find  a 
course  consonant  with  the  interests  of  the  community  as  well  as 
the  demands  of  justice,  with  the  general  notions  as  to  morality 
as  well  as  the  personal  liberty  of  the  subject  are  exceedingly 
great.1 

To  enter  into  a  minute  discussion  of  these  questions  is  not 
within  the  domain  of  medicine,  and  we  must  rest  contented  with 
having  drawn  the  attention  to  the  subject  of  all  those  whom  it 
concerns,  and  with  being  the  instigators  of  an  agitation  that 
ways  and  means  shall  be  found  to  produce  an  amelioration  of 
the  conditions  above  mentioned. 

It  is  idle  to  entertain  the  hope  that  the  State  and  society 
will  ever  succeed  by  regulations,  no  matter  how  carefully 
planned  and  even  if  they  were  so  exacting  as  those  demanded 
by  Plato  for  his  best  State,  to  create  exclusively  ideal  marriages, 
but  it  is  not  unreasonable  to  hope  that  increased  vigilance  with 
regard  to  the  sanitary  conditions  of  marriage  will  result  in  the 
avoidance  of  a  mass  of  disease  and  misery  and  in  rendering  so 
many  marriages  happy  that  there  shall  be  every  justification  for 
Goethe's  poetical  description  of  the  matrimonial  state  (Die 
Natuerliche  Tochter,  Act  4,  Scene  2 ) . 

,,Vollbestand 

Erwunschter  Lebensgiiter  sind  wir  ihm, 
Sowie  der  Zukunft  hochste  Bilder  schuldig. 
Als  allgemeines  Menschengut  verordnet's 
Der  Himmel  selbst,  und  Hess  dem  Gliick,  der  Kiihnheit 
Und  stiller  Neigung  Raum,  sich's  zu  erwerben." 


'That  these  difficulties  are  not  insurmountable  in  every  respect  is 
evidenced  by  the  proposals  recently  made  by  such  eminent  jurists  as 
Prof.  v.  Liszt  and  Prof.  Hellwig  (Zeitschrift  zur  Bekaempfung  von 
Geschlechtskrankheiten,  i,  1903),  with  a  view  to  preventing  the  spread  of 
disease  by  sufferers  from  venereal  affections.  It  might  be  worth  consid- 
ering whether  it  is  not  possible  to  propose  and  introduce  similar  measures 
of  protection  from  the  dangers  arising  from  other  diseases  f.  i.  drunken- 
ness. 


II 

The   Hygienic  Significance  of  Marriage 


II 

The   Hygienic  Significance  of  Marriage 
By  Professor  M.  Gruber  (Munich) 

I.  Necessity  of  regulating  sexual  intercourse. 

— Sexual  instinct  makes  of  the  individual  an  instrument  of  pro- 
creation. In  associating  the  performance  of  the  procreative  act 
with  the  highest  pleasurable  sensations  nature  has  taken  care 
that  the  individual  shall  not  shirk  his  duty,  that  the  stream  of 
life  shall  not  dry  up.  But  while  the  desire  is  so  strong  and  its 
gratification  so  agreeable  it  presents  many  dangers  both  to  the 
individuals  fulfilling  it  as  well  as  to  their  descendants.  Of 
course  nature  removes  the  damage  thus  caused  by  destroying 
in  the  course  of  time  the  feeble,  the  degenerate  and  the  diseased. 
But  this  readjustment  takes  place  at  the  cost  of  an  enormous 
amount  of  pain  and  misery,  of  a  wholesale  destruction  of  indi- 
viduals, families,  races  and  nations.  If  the  extent  of  this  mis- 
fortune is  to  be  diminished,  if  these  dangers  are  to  be  avoided 
it  is  necessary  that  the  blind  desire  shall  be  restrained  by  reason, 
and  it  is  certain  that  mankind  has  from  its  earliest  beginnings 
recognized  more  or  less  clearly  the  necessity  of  regulating 
sexual  intercourse  and  attempted  more  or  less  aptly  to  deal  with 
it.  The  more  our  knowledge  of  natural  processes  advances  the 
more  we  become  convinced  of  the  necessity  of  this  regulation, 
and  the  stronger  the  influence  of  this  conviction  on  our  will- 
power the  more  it  is  permissible  to  hope  that  near  generations 
will  treat  the  subject  with  incomparably  greater  wisdom  than 
we  are  capable  of. 

But  not  all  the  fruit  of  the  tree  of  knowledge  is  nutritious 


<7 


1 8  HEALTH,  DISEASE,  MARRIAGE 

and  wholesome.  Reason  and  civilisation  can  show  the  way  also 
to  the  unnatural,  and  consequently  to  new  dangers  and  injuries 
of  moral  and  material  kinds.  The  temptation  is  particularly 
great  to  deprive  nature  of  her  reward  and  to  try  whether  and 
how  it  is  possible  to  enjoy  the  delights  of  love  without  taking 
upon  oneself  the  burdens  of  procreation.  The  more  cynical  an 
individual  is  in  the  satisfaction  of  his  own  selfish  ends  and  in 
seeking  pleasures  without  regard  to  others  the  more  frequently 
and  the  more  completely  he  will  succumb  to  that  temptation. 

But  nature  will  hardly  allow  anyone  to  impose  on  her  with 
impunity,  and  most  of  these  attempts  result  in  the  end  in  bodily 
harm  to  their  originators.  Even  though  the  individual  escape 
unpunished  it  is  the  community,  the  nation,  which  suffers  where 
the  evil  assumes  large  proportions;  not  only  because  the  natural 
increase  of  the  population  remains  at  a  standstill  but  much  more 
on  account  of  the  diminished  family  sentiment — that  source  of 
humanity  which  is  hardly  capable  of  substitution. 

There  is  certainly  no  exaggeration  in  regarding  a  well- 
regulated  and  yet  natural  sexual  life  of  a  nation  as  the  indis- 
pensable foundation  of  its  permanent  spiritual  and  physical 
health.  A  nation  which  seeks  in  sexual  life  nothing  but  pleasure 
is  bound  to  disappear.  The  future  belongs  to  the  race  that 
regulates  its  sexual  life  with  a  view  to  procreating  a  strong  and 
mentally  efficient  progeny. 

It  has  been  prophesied  that  the  medical  profession  will 
become  the  leading  element  of  the  nations.  If  this  prophecy  is 
to  prove  true  it  becomes  primarily  necessary  that  medical  men 
should  fully  realise  the  enormous  importance  of  a  regulated 
sexual  life  in  the  procreation  and  formation  of  healthy  and 
capable  descendants,  so  that  they  may  as  the  hygienic  advisers 
of  individuals  and  families  unceasingly  spread  and  keep  alive 
this  conception  with  all  its  consequences.  Only  he  is  fit  to  be 
the  leader  of  a  nation  who  feels  from  the  bottom  of  his  heart 
that  man  can  only  prosper  in  his  capacity  as  part  of  society,  that 
is  as  a  moral  being! 

II.  Hygienic  advantages  of  marriage,  a.  Pro- 
longation of  the  life  of  married  individuals.— 
There  can  be  no  doubt  that  monogamous  permanent  marriage 


HYGIENIC  SIGNIFICANCE  OF  MARRIAGE     19 

which  appears  to  be  a  most  natural  consequence  of  the  numerical 
proportion  of  the  sexes  is  morally  as  well  as  hygienically  the 
best  system  for  the  gratification  of  the  sexual  desire. 

Marriage  is  in  the  first  instance  like  all  our  modern  social 
and  civilised  institutions  an  arrangement  which  is  of  the  highest 
benefit  to  the  health  of  the  married  persons  themselves.  This 
statement  applies  fully,  as  statistics  of  mortality  point  out,  with 
regard  to  all  men  over  twenty  years  of  age;  with  regard  to 
women  not  before  the  fortieth  year,  since  many  of  them  are 
during  the  child-bearing  period  liable  to  succumb  to  the  dangers 
that  accompany  the  sexual  life  of  the  female,  many  of  which 
however,  it  is  scarcely  necessary  to  mention  here,  can  be  avoided 
by  rational  midwifery  and  an  appropriate  care  of  the  puerperal 
woman. 

Since  as  the  statistics  of  all  European  countries  show  the 
same  results,  only  those  of  Sweden  are  here  given  as  an  example. 

TABLE  I.1 

Sweden,  1881-90 — Of  1,000  persons  of  each  age-class, 
there  died  annually: 


Males 

Females 

Age 

Widow- 

Widow- 

Years 

Single 

Married 

ers  and 
Di- 

Total 

Single 

Married 

ers  and 
Di- 

Total 

vorced 

vorced 

2O 

6.10 

4.64 

_ 

6.09 

4-85 

6.40 

9-95 

4.96 

25 

7-59 

4.28 

10.15 

6-74 

5-66 

6.16 

9-41 

5-85 

30 

9.20 

4-95 

8.00 

6-73 

6.42 

6-37 

10.23 

6-44 

35 

11.24 

5-68 

10.76 

7.11 

7.02 

6.96 

10.  16 

7.06 

40 

14.67 

7.42 

12.89 

8-75 

8.13 

7-94 

9-50 

8.06 

45 

19.07 

9.22 

13-75 

10.62 

10.15 

8.04 

9-99 

8.60 

50 

22.75 

11.68 

17-35 

I3-I5 

12.18 

8-99 

11.88 

9-90 

55 

28.68 

15.40 

21.62 

17.09 

17.07 

12.31 

15-53 

13.64 

60 

37.16 

22.11 

29.96 

24-33 

23.22 

17.24 

21.  18 

I9-I3 

65 

49.42 

31-45 

40.23 

34-44 

34-74 

27.00 

31-33 

29-59 

70 

70.40 

47-95 

58.65 

52.55 

49-93 

42.76 

48.82 

46.52 

80 

138.90 

121.42 

142.97 

134.10 

127.66 

105-31 

119-34 

H7-73 

90 

234-58 

274.78 

318.97 

306.47    ! 

293-H 

235-04 

268.45 

268.00 

It  is  very  important  that  we  should  have  a  clear  idea  wherein 


15".    Westergaard,   Die  Lehre  von   der  Mortalitiit  und   Morbilitat,   2nd 
Edit.  Jena,  1901.  Fischer,  p.  228. 


20  HEALTH,  DISEASE,  MARRIAGE 

the  favourable  influence  of  marriage  lies.  An  attempt  has  been 
made  to  prove  by  these  statistics  that  sexual  intercourse  is  a 
healthful  necessity.  But  not  only  does  this  view  rest  on  a 
foundation  far  too  ingenuous  for  modern  conditions,  namely, 
that  all  single  men  are  as  a  matter  of  course  continent;  it  is 
inadmissible  because  there  is  more  than  one  factor  contributing 
to  produce  a  lower  mortality  among  married  persons  than  among 
those  living  singly.  The  fact  that  monks  and  nuns  do  not  gen- 
erally show  a  materially  higher  mortality  than  is  the  average 
of  their  respective  ages  (Deparcieux)  does  not  seem  to  indicate 
that  the  frequent  sexual  intercourse  of  married  life  is  beneficial 
to  health  in  a  marked  degree. 

Among  the  lower  classes  the  opinion  prevails  and  for  easily 
comprehensible  reasons  is  assiduously  imparted  by  the  husbands 
to  their  wives  that  sexual  intercourse  or  the  frequent  discharge 
of  semen  is  of  absolute  necessity  to  the  health  of  the  man. 
Science  however  cannot  subscribe  to  this.  It  is  absurd  to  regard 
the  seminal  fluid  as  an  injurious  secretion  which  requires  regular 
evacuation  like  f.  i.  the  urine.  There  is  probably  no  doubt  that 
part  of  the  semen  is  not  only  reabsorbed  during  sexual  abstemi- 
ousness (perhaps  in  the  vesiculse  seminales,  /.  Exner1)  ;  but 
that  this  reabsorption  seems  to  have  even  a  beneficial  effect  on 
the  constitution  if  we  may  judge  by  the  experiences  of  athletes, 
sportsmen,  scholars  and  artists  who  feel  most  fit  for  work  when 
refraining  entirely  from  sexual  intercourse.  It  has  been  proved 
by  Zoth  and  Pregel2  with  certainty  that  the  testicular  extract 
of  Brown-Sequard  has  a  decidedly  beneficial  effect  on  nutrition 
and  bodily  strength  and  that  it  favours  particularly  the  activity 
of  the  nervous  and  muscular  systems.  This  is  evidenced  by 
increased  muscular  action,  a  diminished  sense  of  fatigue  and 
enhanced  recuperativeness.  The  development  of  secondary 
sexual  characters,  physical  and  psychical,  are  doubtless  also  due 
to  the  reabsorption  of  the  secretion  from  the  seminal  glands. 
Whether  it  is  the  direct  constituents  of  the  seminal  fluid  that 
come  into  question  or,  which  is  more  probable  judging  from  the 


'Handbuch  der  Urologie,  ed.  by  v.   Frisch  and  Zuckerkandl.     Vienna, 
1903. 

'Pfliiger's  Archiv.   Vol.  62,  p.  235  and  Vol.  69,  p.  386. 


HYGIENIC  SIGNIFICANCE  OF  MARRIAGE     21 

analogy  between  the  male  and  the  female,  another  "internal" 
secretion,  is  here  quite  immaterial.  In  any  case,  this  reabsorp- 
tion  acts  favourably,  as  is  also  shown  by  comparing  normal 
men  and  women  with  castrated  individuals. 

Nevertheless  it  is  conceivable  that  the  tonic  and  irritating 
influence  of  the  seminal  fluid  may  under  circumstances  become 
too  strong  and  that  its  continued  reabsorption  may  cause  a  kind 
of  "loading"  of  the  nervous  system  which  requires  periodical 
"unloading"  by  means  of  the  sexual  act. 

It  is  also  possible  that  the  reabsorption  does  not  keep  pace 
with  the  secretion  so  that  injurious  congestions  of  the  latter  take 
place  in  the  seminal  glands  and  their  ducts  which  need 
removing. 

To  these  conjectures  it  is  possible  to  reply  that  the  testicles 
behave  like  all  other  organs ;  namely  that  their  blood  supply  and 
consequently  their  activity  is  increased  by  use  and  diminished 
by  non-use.  (See  the  researches  of  Lode1  on  the  quantity  of 
spermatozoa  in  the  semen.)  Moreover  accumulations  of 
seminal  fluid  are  hardly  possible  as  the  secretion  is  generally 
discharged  by  means  of  nocturnal  emissions  which  so  long  as 
they  do  not  occur  too  frequently  must  be  regarded  as  a  physio- 
logical process. 

There  appears  to  be  no  doubt  that  the  majority  of  normal 
men  can  no  less  than  women  permanently  renounce  sexual  inter- 
course or  the  gratification  of  the  sexual  desire  altogether  without 
suffering  any  injury.  Those  who  do  not  believe  in  the  experi- 
ences of  man  may  judge  from  what  we  see  in  our  domestic 
animals.  Stallions  and  mares,  male  and  female  dogs  remain 
healthy  though  they  are  not  allowed  to  copulate. 

It  is  of  course  presumed  that  every  intentional  and  artificial 
excitement  of  the  sexual  instinct  is  avoided,  otherwise  it  is  possi- 
ble for  the  desire  to  assume  the  character  of  a  forcible 
impulse. 

All  possible  ill-effects  have  been  attributed  to  continence. 
In  man,  nervous  irritability,  insomnia,  headache,  a  feeling  of 
tension  and  oppression  in  the  pelvic  region,  pain  in  the  testicles 


'•P finger's  Archiv.  Vol.  50,  1891,  p.  278. 


22  HEALTH,  DISEASE,  MARRIAGE 

and  in  the  spermatic  cord,  varicocele,  morbidly  frequent  and 
exhausting  emissions,  spermatorrhoea  (accompanying  defaeca- 
tion),  impotence,  satyriasis,  etc.  But  most  of  these  mani- 
festations are  not  due  to  continence.  They  are  more  likely 
the  consequence  of  sexual  over-indulgence,  especially  reckless 
masturbation,  or  as  is  the  case  with  satyriasis  of  demonstrable 
disease  of  the  genital  organs  themselves  or  of  the  central 
nervous  system.  As  regards  the  minor  ailments  which  may 
perhaps  to  a  certain  extent  really  be  associated  with  continence 
they  are  easily  combated  by  a  hygienically  proper  mode  of  life 
(cold  sponging,  cold  baths,  physical  exercise,  abstinence  from 
alcohol  and  other  irritating  substances,  a  cool  and  not  too  soft 
bed,  etc.). 

Leucorrhoea  and  nymphomania  in  females  are  likewise 
hardly  ever  the  product  of  continence  but  exceedingly  often  that 
of  sexual  intemperance  or  unrestrained  masturbation.  That 
some  diseases  which  are  also  attributed  to  continence  as  f.  i. 
tumours  of  the  uterus  and  hysteria  have  nothing  to  do  with  it 
is  sufficiently  proved  by  the  fact  that  they  are  more  often  pres- 
ent in  married  women  and  mothers  than  in  virgins.  The  opinion 
that  genuine  chlorosis  can  be  cured  by  marriage  and  pregnancy 
has  long  since  been  found  to  be  erroneous. 

It  is  true  that  suicide  is  more  frequent  among  single  than 
among  married  persons;  but  the  rarity  of  love  as  the  inciting 
cause  of  suicide  (3-6%)  tends  to  show  that  the  ungratified 
sexual  desire  plays  no  important  factor  in  such  cases.  More- 
over, it  is  very  questionable  whether  all  unmarried  suicides  are 
chaste. 

I  have  gone  so  minutely  into  the  question  of  the  injuri- 
ousness  of  continence  because  many  individuals  are  either  per- 
manently or  at  any  rate  for  a  time  obliged  to  forego  the  idea 
of  marriage;  because  during  married  life  also  long  periods 
occur  in  which  sexual  intercourse  is  impossible  or  not  permissi- 
ble and  because  there  are  unfortunately  medical  men  yet  to  be 
found  who  carelessly  recommend  non-connubial  intercourse  to 
patients,  who  find  themselves  in  such  circumstances,  as  a  means 
of  combating  the  alleged  harmfulness  of  continence.  These 
practitioners  forget  the  enormous  risks  of  venereal  disease  to 


HYGIENIC  SIGNIFICANCE  OF  MARRIAGE     23 

which  they  advise  their  patients  to  expose  themselves — not  to 
speak  of  the  objectionable  and  immoral  character  of  such 
council. 

It  is  consequently  not  the  frequent  gratification  of  the  sexual 
desire  which  constitutes  the  cause  of  the  remarkable  compara- 
tive longevity  of  married  men.  It  may  rather  be  taken  for 
granted  that  their  more  orderly  and  regulated  mode  of  life,  the, 
on  an  average,  lesser  abuse  of  alcohol  and  the  relative  infre- 
quency  of  venereal  infection  and  of  its  consequences  are  the 
factors  which  play  the  principal  part. 

There  is  of  course  one  other  item  which  deserves  mention 
as  apparently  contributing  to  the  beneficial  influence  of  mar- 
riage. Marriage  involves  even  in  our  present  day  a  certain 
selection  of  the  fittest,  though  not  a  sufficient  one,  inasmuch  as 
highly  degenerate  individuals  such  as  idiots,  lunatics,  cripples, 
lame  or  blind  persons,  etc.,  are  as  a  rule  excluded  from  it.  The 
quality  of  the  married  class  is  therefore,  to  begin  with,  some- 
what better  than  that  of  the  single  class.  As  a  matter  of  fact 
it  has  been  attempted  to  attribute  the  whole  of  the  difference 
in  the  mortality  of  the  two  classes  to  this  circumstance  alone — 
but  hardly  with  any  justification.  Against  this  one-sided  view 
we  must  remember  that  married  persons  show  a  lower  mortality 
at  all  ages — even  the  highest,  whereas  the  disappearance  of  the 
degenerates  should  on  the  whole  be  completed  during  the  earlier 
years. 

It  has  also  been  suggested  that  the  case  rests  upon  the 
economically  superior  position  of  those  who  can  afford  to  marry 
and  that  it  is  only  a  special  result  of  the  beneficial  effects  of 
affluence.  But  this  is  certainly  not  true.  The  bulk  of  the  people 
marry  without  troubling  much  about  the  future  and  if  any  mar- 
ried couples  have  at  the  commencement  of  their  married  life 
a  certain  material  advantage  it  soon  gets  lost  where  there  are 
children  to  be  brought  up. 

That  it  is  not  the  selection  but  the  married  state  itself 
which  is  the  favourable  factor  can  also  be  seen  from  the  high 
mortality  among  the  widowed  and  the  divorced.  (See  Table  I.) 
In  any  case  it  is  an  important  fact  that  the  contraction  of  mar- 
riage signifies  an  increase  in  the  mean  expectation  of  life. 


24  HEALTH,  DISEASE,  MARRIAGE 

Prinzing1  has  calculated  for  Bavaria  that  a  married  man  aged 
30  has  an  expectation  of  life  longer  by  5  years  than  a  bachelor 
of  the  same  age,  and  a  married  woman  in  spite  of  the  dangers 
of  pregnancy  and  child-bed  one  longer  by  one  year  than  a 
spinster  of  the  corresponding  age. 

b.  Advantages  to  the  offspring. — If  marriage  is 
an  important  hygienic  institution  from  the  point  of  view  dis- 
cussed so  far,  it  is  even  to  a  greater  extent  a  safeguard  to  the 
succeeding  generation.  The  fruit  of  connubial  intercourse  is,  to 
begin  with,  better  protected  in  the  mothers'  wombs  than  is  the 
illegitimate  child,  it  has  much  better  chances  to  withstand  the 
perturbations  of  labour,  better  prospects  of  receiving  at  the 
mothers'  breasts  the  nourishment  provided  by  nature  and  is 
usually  looked  after  with  greater  attention  during  the  early 
years,  so  full  of  dangers,  as  well  as  afterwards.  Herein  lies 
the  great  interest  which  society  and  the  State  have  in  marriage 
and  in  the  prevention  of  the  procreation  of  illegitimate  children. 
On  these  points  also,  statistics  show  everywhere  the  same  results. 
The  subjoined  table  gives  a  comparison  of  the  numbers  of  still- 
births in  different  European  countries  for  the  year  1893-94. 


TABLE  II.2 

Of  1,000  births  there  were  still  births 


Legiti- 
mate 
Births 

Illegiti- 
mate 
Births 

Legiti- 
mate 
Births 

Illegiti- 
mate 
Births 

Italy     

"1Q 

CI 

Prussia    . 

•3,2 

46 

France      .... 

A4 

74. 

Austria    . 

27 

*12 

Belgium    .     .     . 

43 

63 

Hungary 

23 

31 

Holland     .     .     . 

44 

81 

Denmark 

24 

32 

Wurtemberg 

32 

35 

Norway  . 

27 

41 

Bavaria     .     .     . 

30 

36 

Sweden   . 

25 

33 

Saxony      .     .     . 

32 

4i 

Finland  . 

26 

47 

As  regards  the  mortality  of  children  born  alive  the  follow- 
ing figures,  worked  out  by  Boeckh  after  a  most  careful  study 


'Allgemeines  statist.  Archiv.  V.  1898. 
tWestergaard,  loc.  cit.  p.  348. 


HYGIENIC  SIGNIFICANCE  OF  MARRIAGE     25 

of  the  Berlin  statistics  for  the  year   1885,  Wl^-  serve  as  an 
example : 

TABLE  III.1 

Berlin,  1885. 
Of  1,000  births  there  survived: 


Age 

Legiti- 
mate 

Illegiti- 
mate 

A| 

i'e 

Legiti- 
mate 

Illegiti- 
mate 

Birth   .     . 

06^ 

04.  a 

1  5/  ve 

;\r 

7OQ 

488 

i  Month 

911 

828 

i% 

691 

471 

2  Months 

889 

767 

itf 

679 

455 

3 

868 

716 

1  2    yea 

rs 

669 

446 

6 

813 

613 

3 

642 

425 

9 

769 

557 

1  4 

624 

412 

12 

735 

515 

I5 

612 

405 

If  we  examine  into  the  causes  of  death  among  illegitimate 
children  we  find  that  those  which  emanate  from  digestive  dis- 
turbances predominate.  And  this  is  easy  to  understand.  For  it 
is  obvious  that  illegitimate  children  are  not  as  often  breast-fed 
as  those  born  in  wedlock  and  that  less  care  is  exercised  in  their 
artificial  nutrition. 

III.  Injuriousness  of  marriage  where  health 
is  defective  or  age  unsuitable. — Sexual  intercourse  is 
hygienically  permissible  only  to  such  persons  who  are  sexually 
perfectly  mature,  healthy  and  in  full  vigour,  as  only  from 
healthy  and  mature  parents  can  a  healthy  progeny  be  expected. 
If  immature  persons  marry  the  premature  sexual  intercourse 
is  as  injurious  to  them  as  it  is  to  unmarried  individuals,  and 
this  is  proved  by  the  markedly  higher  mortality  among  young 
married  people  when  compared  with  those  that  are  not  mar- 
ried. This  difference  is  particularly  noticeable  in  the  case  of 
young  men.  Thus  there  died  in  Oldenburg  in  the  years  1876-85 
annually  on  an  average:  out  of  1,000  single  men  between  15 
and  20  years  old,  6.3;  out  of  1,000  married,  8.7;  out  of  1,000 
unmarried  women  of  the  same  ages,  5.7;  out  of  1,000  mar- 
ried, 6.2. 

Persons  of  advanced  age  should  also  be  dissuaded  from 


JQuoted  by  Wcstergaard,  1.  c.  p.  391. 


26  HEALTH,  DISEASE,  MARRIAGE 

marrying  just  like  those  who  are  immature.  I  know  quite  a  large 
number  of  cases  where  men  over  50  years  of  age  were  no  longer 
equal  to  the  demands  of  a  new  marriage ;  it  was  particularly  the 
heart  and  the  blood-vessels  that  could  not  stand  the  severe 
"rush  of  blood." 

IV.  The  constitution  of  the  offspring  de= 
pendent  on  that  of  the  parents. — Of  the  greatest 
importance  to  the  succeeding  generation  is  the  physical  con- 
stitution of  the  parents.  This  is  a  fact  which  is  very 
insufficiently  recognised  by  the  laity  as  well  as  by  the  medical 
profession.  It  ought  to  be  the  guiding  standpoint  at  the  con- 
traction of  marriages  and  while  exercising  the  procreative  act 
during  marriage,  that  it  is  a  dereliction  of  duty  to  bring  chil- 
dren into  the  world  which  will  probably  be  the  subjects  of 
congenital  anomalies,  affected  with  disease,  or  a  predisposition 
to  disease  or  devoid  of  vitality  and  unable  to  resist  against 
extraneous  injuries. 

There  is  no  need  for  me  to  explain  to  my  medical  readers 
that  we  are  in  everything  essential  the  creatures  of  our  parents 
and  of  our  ancestors,  that  it  is  on  the  whole  predestined  by  the 
nature  of  the  germs  from  the  combination  of  which  we  emanate 
what  we  are  and  what  we  are  to  be. 

By  no  means  everything  that  is  given  us  is  good!  The 
parental  germs  themselves  may,  to  begin  with,  be  possessed  of 
inherited  deficiencies,  or  they  may  have  suffered  by  injuries 
which  affected  the  parental  body,  or  they  may  not  have  been 
perfect  on  account  of  the  immature  or  too  advanced  age  of 
the  parents.  I  do  not  mean  in  this  short  survey  to  go  at  all 
into  the  complicated  question  whether  so-called  "acquired 
peculiarities"  of  the  parents  can  be  inherited  by  their  descend- 
ants. Though  the  theoretical  interest  in  this  point  is  very  great 
it  has  not  practically  that  high  importance  which  has  been 
attributed  to  it.  Thus  f.  i.  the  question  whether  a  tuberculous 
father  from  whom  his  descendants  have  inherited  a  predis- 
position to  tuberculosis  was  himself  hereditarily  predisposed  to 
the  disease  may  be  very  interesting,  but  what  is  practically 
important  is  the  undoubted  fact  that  tuberculous  fathers 
bequeath  exceedingly  often  a  predisposition  to  tuberculosis. 


27 

I  will  now  enumerate  briefly  what  we  know  of  the  injuries 
to  and  the  deficiencies  of  the  germ-substances  which  are  trans- 
missible to  the  progeny  : 

a.  Age  of  the  parents. — Where     the     parents     are 
much  too  young  (mother  under  20,  father  under  27)  the  chil- 
dren are  not  infrequently  delicate;  malformations  and  idiocy 
are  also  more  frequent  among  the  children  of  young  parents 
than  among  those  of  the  fully  mature. 

Equally  unfavourable  is  advanced  age  of  the  parents 
(mother  above  40,  father  above  50).  It  is  worth  mentioning 
that  very  young  mothers  and  those  approaching  the  climac- 
terium  are  more  prone  to  give  birth  to  twins  than  women  in 
their  prime. 

b.  Number  and  rate  of  successive  pregnan* 
cies. — All  that  weakens  the  organism  of  the  parents  acts  in 
the  majority  of  cases  debilitatingly  on  the  descendants  also,  and 
this  is  particularly  the  case  where  the  mother  is  delicate,  either 
because  the  ovum  possesses  little  vitality  or  because  the  nutri- 
tion of  the  embryo  is  insufficient.    It  is  here  necessary  to  point 
out  that  the  maternal  organism  suffers  in  a  manner  calculated 
to  injure  the  descendants  where  pregnancies  follow  each  other 
too   rapidly  or  where  they  are  too  numerous.      Statistics  of 
infantile  mortality  show  that  on  an  average  the  third  and  fourth 
child  of  the  same  woman  are  the  strongest  and  that  beginning 
with  the  fifth,  sometimes  with  the  fourth,  their  vitality  dimin- 
ishes pretty  rapidly.    The  unfavourable  influence  is  especially 
great  where  pregnancies   follow  each  other  within  one  year. 
W ester gaard1  has  worked  out  that  out  of   100  children  who 
were  born  within  one  year  after  a  brother  or  a  sister  19.9  died 
before  they  reached  their  5th  year;  but  out  of  100  who  were 
younger  by  more  than  two  years,  only  n.8.    Even  those  chil- 
dren who  were  born  between  one  and  two  years  after  their 
predecessors  showed  a  fairly  higher  mortality  than  children 
who    followed   after   a    longer    interval.     Pregnancies    should 
therefore  not  succeed  one  another  more  rapidly  than  at  inter- 
vals of  two  and  a  half  years.    Only  thus  it  is  possible  for  a 
mother  to  suckle  her  children  sufficiently  long. 

1Loc.  cit.  p.  371. 


28 

c.  Economic  conditions. — If   the   younger  children 
of  prolific  marriages  are  on  an  average  weaker  than  the  older 
ones,  this  is  partly  due  to  economic  conditions.    The  greater 
the  number  of  children  the  more  difficult  it  becomes  to  provide 
them  with  sufficient  and  good  nourishment  and  to  bring  them 
up  with  the  necessary  care.   For  this  reason  also  the  unrestrained 
and  proletarian  procreation  of  children  is  open  to  objection. 
There  should  be  no  more  children  brought  into  the  world  than 
can  presumably  be  fed  and  reared. 

d.  Diseases  of  the  parents. — Many     chronic     and 
exhausting  diseases  are  productive  in  the  descendants  of  feeble 
vitality,  diminished  resistibility,  slow  and  incomplete  develop- 
ment, and  sometimes  of  diseases  or  predispositions  to  disease 
which  are  characteristic  of  the  respective  parental  conditions. 

This  applies  especially  to  certain  chronic  metallic  intoxica- 
tions (as  f.  i.  lead-poisoning)  which  are  harmful  to  the  chil- 
dren if  either  the  father  or  the  mother  suffers  from  them, 
syphilis,  tuberculosis,  mental  and  nervous  diseases,  alcoholism 
and  morphinism. 

It  is  well  known  that  syphilis  can  be  transmitted  directly 
from  parents  to  children,  thus  giving  rise  to  congenital  second- 
ary or  tertiary  lesions.  The  infection  may  proceed  either  from 
the  father  or  from  the  mother.  But  even  when  they  do  not 
actually  receive  the  infective  virus,  the  children  suffer  through 
the  parental  syphilis,  as  is  proved  by  the  large  number  of  mis- 
carriages and  still-births  and  also  by  the  great  infantile  mor- 
tality and  by  the  frequent  occurrence  of  stunted  and  backward 
children  among  the  offspring  of  syphilitic  individuals.  It  has 
already  been  mentioned  that  such  children  are  frequently  highly 
predisposed  to  tubefculosis. 

The  children  of  tuberculous  parents  become  themselves 
very  often  tuberculous.  It  is  probably  very  seldom  indeed  that 
they  are  infected  with  tubercle  bacilli  directly  at  the  conception 
or  during  pregnancy,  as  is  the  case  with  syphilis  and  some  other 
infectious  diseases  such  as  small-pox,  scarlet  fever,  etc.;  at  least 
it  would  seem  so  judging  from  the  exceedingly  small  number  of 
people  affected  with  congenital  tuberculous  processes  of  a  mani- 
fest character,  and  also  from  the  fact  that  not  in  one  single 


HYGIENIC  SIGNIFICANCE  OF  MARRIAGE     29 

case  has  an  inherited  infection  been  traced  to  the  paternal 
semen.  To  some  extent  the  frequency  of  tuberculosis  among 
the  children  of  tuberculous  parents  is  probably  due  not  so  much 
to  direct  hereditary  transmission  as  to  the  circumstance  that 
in  their  extra-uterine  life  such  children  are  as  a  rule  in  a  very 
marked  degree  exposed  to  the  danger  of  infection. 

It  would  however  in  our  opinion  be  altogether  wrong  to 
attribute  the  occurrence  to  the  last-mentioned  factor  only.  It 
seems  to  us  to  be  established  beyond  doubt  that  the  children 
of  tuberculous  parents  are  not  only  very  often  of  weakly  con- 
stitution and  ill  developed  like  the  children  of  parents  suffering 
from  any  chronic  disease,  but  that  they  possess  a  specific  inclina- 
tion to  tuberculosis.  This  view  derives  support  from  those  well- 
known  sad  cases  where  all  or  almost  all  of  the  children  of  a 
family  succumb  more  or  less  rapidly  to  tuberculosis  after  having 
reached  apparently  in  perfect  health  the  second  or  third  decade. 

Very  often  indeed  the  whole  physical  constitution  of  descend- 
ants from  tuberculous  parents  is  so  characteristic  that  we 
speak  of  a  tuberculous  habit  of  body  or  diathesis;  tall  stature, 
long  and  flat  thorax,  overhanging  shoulders,  weak  muscles,  a 
poor  general  state  of  nutrition,  a  small  heart,  narrow  blood- 
vessels, irritability  of  temper  and  limited  nervous  endurance. 

An  incontestable  fact  is  also  the  frequent  hereditary  trans- 
mission of  a  predisposition  to  mental  disturbances  and  nervous 
diseases  from  one  generation  to  another.  What  is  characteristic 
in  these  cases  is  the  extraordinary  diversity  of  forms  which  the 
disease  assumes  and  in  which  the  inherited  degeneration  or 
deficiency  of  the  nervous  system  becomes  apparent.  All  kinds 
of  nervous  disease  may  be  noticed,  from  light  manifestations 
of  irritability,  eccentric  tendencies  and  hypochondriasis  to  the 
severest  forms  of  epilepsy,  insanity  and  idiocy. 

It  cannot  be  sufficiently  emphasized  how  injurious  the  abuse 
of  alcohol  is  to  the  succeeding  generation.  This  harmfulness  of 
alcohol  manifests  itself  on  the  one  hand  like  that  of  other 
poisons  by  a  generally  impaired  vitality,  development  and 
resistibility  of  the  child  and  again  specially  in  a  severe  derange- 
ment of  the  nervous  system  which  is  apt  to  assume  the  most 
variable  forms. 


30  HEALTH,  DISEASE,  MARRIAGE 

e.  Inherited  defects  of  the  germinal  cells.— 

Certain  morbid  predispositions  are  inherited  from  generation 
to  generation  and  are  doubtless  based  upon  some  specific 
defect  in  the  embryonic  elements.  It  is  however  particularly 
worth  mentioning  that  a  link  in  the  chain  of  the  generations 
may  now  and  then  escape  the  disease  though  the  predisposition 
to  it  has  been  latently  inherited,  as  f.  i.  by  grandchildren  from 
their  grandparents,  etc.  (atavism). 

Here  again  mention  must  be  made  above  all  of  the  mental 
and  nervous  diseases  which  often  cling  tenaciously  to  some 
families.  In  all  the  severe  cases  of  inherited  predisposition 
the  degeneration  of  the  germinal  elements  is  already  evidenced 
by  outwardly  noticeable  anomalies,  the  so-called  signs  of 
degeneration.  Hereditary  from  generation  to  generation  is 
further  a  predisposition  to  certain  metabolic  disorders;  this  is 
particularly  the  case  with  gout  and  also  with  jaundice,  renal 
calculus,  diabetes  mellitus,  diabetes  insipidus,  alkaptonuria  and 
cystinuria. 

There  is  also  an  inherited  predisposition  to  cancer,  to 
premature  arteriosclerosis  and  consequently  apoplexy,  to  em- 
physema of  the  lungs  and  to  certain  skin  diseases.  It  also  seems 
that  a  tendency  to  tuberculosis  can  be  hereditary  through 
several  generations. 

A  most  remarkable  phenomenon  is  the  hereditary  trans- 
mission of  certain  malformations  which  affect  either  single 
organs  or  extremities  only,  or  the  entire  body.  To  this  category 
belong  the  presence  of  supernumerary  fingers  or  toes,  hare-lip, 
cleft  palate,  non-development  of  the  female  breast,  dwarfs, 
giants,  myopia,  colour  blindness,  hasmeralopia,  hereditary 
cataract,  atrophy  of  the  retina  and  retinitis  pigmentosa,  warts, 
birth-marks  (naevi),  neuromata,  neuro-fibromata,  cartilaginous 
exostoses,  progressive  deafness  in  consequence  of  sclerosis, 
deaf-mutism,  haemophilia,  etc. 

f.  Consanguinity. — It  is  in  the  hereditary  transmissi- 
bility  of  certain  predispositions  to  disease  and  malformations 
where  the  danger  of  procreation  among  blood-relations  lies. 
Such  procreation  is  not  per  se  injurious  or  only  so  when  it  is 
continued  through  many  generations  in  which  case  the  mar- 


HYGIENIC  SIGNIFICANCE  OF  MARRIAGE     31 

riages  may  prove  sterile.  The  disadvantage  is  that  near  rela- 
tions possess  the  same  inherited  predispositions  and  that  a  com- 
bination of  these  injurious  influences  may  attack  the  embryo. 
On  the  other  hand  there  is  an  unfavourable  element  in  the  union 
of  two  individuals  who  spring  from  races  too  wide  apart  as  is 
proved  by  the  limited  fruitfulness  of  such  marriages  f.  i.  of 
those  between  Jews  and  Christians. 

V.  Choice  of  husband  or  -wife. — The  choice  of  a 
husband  or  wife  is  therefore  an  exceedingly  serious  matter. 
But  there  should  not  be  any  exaggeration  about  it.  No  one  is 
perfectly  normal  and  entirely  free  from  inherited  predisposition 
to  disease.  Undue  anxiety  would  result  in  there  being  no  mar- 
riages at  all.  It  must  also  be  borne  in  mind  that  just  as  in 
certain  families  morbid  tendencies  increase  (degenerative 
heredity),  so  in  others  they  diminish;  that  by  a  suitable  mode 
of  life  it  is  possible  to  arrest  certain  predispositions  in  certain 
individuals  (this  applies  f.  i.  to  mental  diseases  and  tuberculosis 
in  a  very  marked  manner)  ;  and  particularly,  that  by  a  con- 
tinued pairing  with  descendants  of  healthy  families  abnormal 
predispositions  may  be  annihilated  altogether;  provided  always 
that  the  degeneration  of  the  germinal  elements  has  not  gone 
too  far. 

We  may  therefore  lay  down  something  like  the  following 
as  a  rational  guide: 

People  afflicted  with  serious  malformations,  degenerates 
such  as  idiots,  imbeciles,  lunatics,  epileptics,  drunkards,  habitual 
criminals  and  chronic  sufferers,  such  as  tuberculous  persons  and 
syphilitics  in  the  secondary  stage,  should  absolutely  be  excluded 
from  procreation.  Equally  unsuitable  as  procreators  are  indi- 
viduals whose  physical  development  is  not  complete  or  whose 
sexual  character  is  imperfectly  marked.  It  is  particularly  neces- 
sary to  dissuade  from  marriage  women  with  poorly  developed 
breasts  and  hips,  women  who  have  never  menstruated  or  men- 
struated irregularly  and  women  with  ill-developed  and  imper- 
fect pelves  as  a  consequence  of  rickets.  In  fact  only  such  per- 
sons should  beget  children  who  are  perfectly  healthy,  strong 
and  well-nourished.  Individuals  who  are  either  too  young  or 
too  old  are  unsuitable  for  procreative  purposes. 


32  HEALTH,  DISEASE,  MARRIAGE 

It  is  essential  to  make  inquiries  into  the  history  of  the 
ascendants  of  persons  about  to  marry.  Important  above  every- 
thing in  this  connection  is  the  physical  constitution  of  the  parents 
and  of  the  brothers  and  sisters.  But  we  must  try  to  go  as  far 
back  as  possible,  especially  where  the  antecedents  of  the  parents 
and  of  their  brothers  and  sisters,  as  well  as  those  of  the  brothers 
and  sisters  of  the  candidate  for  marriage  are  not  quite  satisfac- 
tory. The  further  back  the  anomalies  and  morbid  predisposi- 
tions are  demonstrable  among  the  ascendants,  the  more  fre- 
quently they  have  occurred  among  the  members  of  any  one 
generation,  the  more  marked  those  abnormalities  and  signs  of 
degeneration  are,  so  the  more  the  individual  in  question  is 
himself  or  herself  predisposed,  and  the  probability  greater,  that 
he  or  she  will  be  equally  affected  or  transmit  that  predisposi- 
tion to  the  subsequent  generation.  If  the  particular  abnormality 
or  degenerative  sign  is  serious,  procreation  must  not  take  place 
under  any  circumstances,  even  if  the  individual  in  question  may 
for  the  time  being  appear  to  be  in  perfect  health.  The  more 
insignificant  the  hereditary  susceptibility,  both  as  regards  the 
nature  of  the  abnormality  and  also  its  degree,  the  more  easy 
it  will  be  to  permit  the  marriage,  or  procreation  respectively,  so 
long  as  the  individual  concerned  may  be  regarded  as  normal. 
The  decision  will  often  be  extraordinarily  difficult  and  fraught 
with  the  most  serious  responsibilities.  In  any  case  it  will  be 
necessary  when  giving  the  permission  to  the  individual  con- 
cerned to  take  great  care  that  the  other  partner  descends  from 
a  stock  in  which  the  same  hereditary  predisposition  is  not  pres- 
ent and  that  the  married  couple  should  in  their  mode  of  life  and 
in  the  procreation  of  children  take  every  precaution  calculated 
to  counteract  the  hereditary  morbid  proclivity.  Marriages 
between  blood-relations  should  always  be  opposed. 

The  choice  of  husband  or  wife  is  however  of  importance 
not  only  from  the  point  of  view  of  the  expected  offspring  but 
also  from  that  of  the  other  partner.  Particular  attention  must 
be  directed  to  the  danger  of  transmission  of  acute  and  chronic 
infectious  diseases  from  husband  to  wife  or  vice-versa.  In  prac- 
tice it  is  principally  tuberculosis  and  venereal  diseases — 
gonorrhoea  and  syphilis — which  come  into  question.  As  regards 


HYGIENIC  SIGNIFICANCE  OF  MARRIAGE     33 

the  former  it  is  at  least  necessary  to  warn  against  the  great  risk 
of  infection  if  it  is  not  possible  to  prevent  the  marriage 
altogether.  Persons  who  have  suffered  from  syphilis  or 
gonorrhoea  must  under  no  circumstances  marry  or  indulge  in 
sexual  intercourse  at  all  until  it  is  absolutely  certain  that  they 
are  no  longer  contagious.  On  this  latter  point  it  is  regrettable 
to  have  to  say  that  many  medical  men  act  with  unpardonable 
carelessness  or  lamentable  ignorance.  No  practitioner  should 
allow  a  syphilitic  individual  to  marry  and  beget  children  before 
the  expiration  of  at  least  three — or  better  still  four — years 
from  the  commencement  of  the  illness,  and  then  only  if  the 
treatment  has  been  a  thorough  one  and  no  symptoms  whatever 
have  shown  themselves  for  at  least  one  year.  As  to  gonorrhoea, 
there  is  hardly  a  medical  man  who  does  not  know  that 
gonorrhoea  in  the  female  when  it  has  once  attacked  the  internal 
organs  is  practically  incurable  and  that  the  chronic  condition 
in  the  male  may  continue  for  years  with  such  slight  manifesta- 
tions that  it  is  possible  only  by  very  frequent  and  most  search- 
ing microscopic  and  endoscopic  examinations  to  obtain  con- 
clusive proof  of  its  disappearance.  It  is  well  known  that  such 
chronic  and  hardly  recognisable  gonorrhoeas  are  capable  of  pro- 
ducing in  healthy  women  most  virulent  acute  attacks  of  the 
disease.  The  responsibility  of  the  practitioner  is  therefore 
enormous  when  giving  his  permission  to  a  patient,  who  has  had 
gonorrhoea,  to  marry.  He  is  entitled  to  grant  that  permission 
only  after  having  exhausted  all  the  means  at  his  disposal  which 
can  enable  him  to  arrive  at  a  definite  conclusion. 

With  regard  to  the  mode  of  life  of  married  individuals  it 
is  the  duty  of  the  physician  to  make  it  clear  to  them  that  they 
must  consider  their  health  not  only  for  their  own  sakes  but 
that  they  should  avoid  everything  that  is  likely  to  injure  it 
for  the  sake  also  of  the  expected  offspring.  The  medical  pro- 
fession ought,  from  this  point  of  view,  to  oppose  to  the  best 
of  their  ability  the  constant  round  of  pleasures  of  which  people 
are  so  fond  and  also  the  habitual  indulgence  in  alcoholic 
liquors  or  other  narcotic  substances. 

Tight-lacing  should  be  opposed,  as  it  may  act  injuriously 
especially  on  the  embryo. 


34  HEALTH,  DISEASE,  MARRIAGE 

All  the  circumstances  which  preclude  marriage  preclude  as 
a  matter  of  course  the  procreation  of  children  if  they  arise  after 
a  marriage  has  taken  place. 

The  practitioner  will  do  well  in  all  cases  where  the  procrea- 
tion of  children  is  permanently  or  temporarily  contra-indicated, 
to  recommend  genuine  sexual  continence.  All  preventive  prac- 
tices which  permit  sexual  intercourse  while  avoiding  conception 
seem,  if  carried  on  for  any  length  of  time,  to  cause  more  or  less 
injury,  and  most  of  them  are  also  unsafe.  This  subject  will  be 
dealt  with  more  minutely  in  a  subsequent  chapter;  it  is  suffi- 
cient to  point  out  here  that  it  is  the  more  important  for  the 
practitioner  to  be  very  careful  in  recommending  these  practices 
as  they  are  apt  to  find  their  way  to  healthy  individuals,  thereby 
causing  injury  to  them  as  well  as  to  the  community  by  preventing 
the  creation  of  a  vigorous  progeny  in  numbers  commensurate 
to  the  strength  and  greatness  of  the  nation. 


Ill 

Congenital   and   Inherited    Diseases   and 
Predispositions   to   Disease 


Ill 

CONGENITAL  AND    INHERITED  DISEASES 
AND  PREDISPOSITIONS   TO  DISEASE 

By  Professor  J.  Orth  (Berlin) 

IN  order  to  obtain  a  clear  conception  of  the  occurrences 
and  significance  of  congenital  and  inherited  diseases  and  pre- 
dispositions to  disease,  it  is  in  the  first  instance  necessary  to 
possess  a  notion  as  to  the  meaning  of  the  words  "inherited," 
"congenital,"  "disease,"  and  "predisposition  to  disease."  This 
is  the  more  requisite  as  medical  terminology  unfortunately  does 
not  in  this  matter  afford  us  any  definite  rules  and  logical  con- 
clusions, and  as,  particularly  in  the  case  of  the  designation 
"predisposition  to  disease"  or  "predisposition"  it  has  often  been 
remarked  that  where  conception  is  at  fault  a  good  name  goes  a 
very  long  way.  The  well-known  saying  of  Bacon,  "Prudens 
interrogatio  est  quasi  dimidium  scientiae"  might  very  well  be 
altered  into  "Prudens  definitio  est  quasi  dimidium  scientiae." 
I  shall  therefore  try  first  to  render  the  ideas  intelligible  and  will 
aftenvards  deal  with  the  occurrence  of  congenital  and  inherited 
diseases  and  predispositions  to  disease  in  general,  but  with 
special  regard  to  the  question  of  heredity  and  its  importance 
in  pathology. 

The  meaning  of  "inherited"  and  "congen- 
ital."— The  words  "inherited"  and  "congenital"  are  often 
used  synonymously,  but  there  is  no  justification  for  it  because 
although  everything  inherited  is  also  congenital,  it  does  not 
necessarily  follow  that  everything  congenital  is  also  inherited. 
The  opposite  of  "inherited"  is  "acquired."  Acquisitions  are 
either  extra-uterine  or  intra-uterine ;  if  the  latter  they  are  con- 
genital, but  inherited. 


38  HEALTH,  DISEASE,  MARRIAGE 

All  is  congenital  that  is  present  in  or  about  an  individual 
at  the  time  or  his  or  her  birth.  It  is  not  essential  that  the  con- 
genital peculiarities  shall  be  recognisable  in  the  newly-born 
infant  immediately  after  birth,  either  by  an  external  or  by  an 
internal  examination;  there  may  be,  to  begin  with,  a  latent 
condition  from  which  the  particular  abnormality  or  peculiarity 
emerges  at  a  subsequent  period,  perhaps  after  many  a  year, 
and  which  though  not  recognisable  at  birth  is  nevertheless 
inherent  in  some  shape.  This  applies  to  normal  as  well  as  to 
abnormal  qualities.  Whether  a  newly-born  infant  is  of  the 
male  or  of  the  female  sex  is  under  ordinary  circumstances 
visible  immediately  after  birth,  but  the  development  of  the 
sexual  glands  or  of  the  female  breast  respectively  does  not  take 
place  before  puberty;  and  as  to  pubic  hair  or  the  beard  there 
is  not  at  birth  a  trace  of  them,  yet  we  do  not  doubt  that  they 
are  congenital  phenomena,  and  that  their  origin  dates  from 
birth. 

Such  latency,  such  an  appearance  of  peculiarities  later  in 
life  is  not  seen  only  in  the  development  of  the  sexual  attributes 
or  in  connection  with  general  conditions  but  also  in  individual 
qualities  and  especially  in  family  characteristics.  Certain 
peculiar  family  features  are  at  times  decidedly  recognisable 
in  newly-born  or  very  young  children;  there  are  however  a 
number  of  peculiarities  as  f.  i.  the  general  build,  facial  expres- 
sions, the  nature  of  the  hair,  and  also  functional  distinctive 
phenomena  and  proclivities,  etc.,  which  make  their  appearance 
at  a  subsequent  period  and  as  to  which  no  one  has  any  doubt 
that  they  are  congenital  possessions. 

The  matter  is  no  different  as  regards  disease.  It  is  f.  i.  well 
known  that  syphilis  is  capable  of  producing  intra-uterine 
symptoms  which  are  recognisable  immediately  after  birth,  that 
in  most  cases  undoubted  signs  of  the  disease  become  apparent 
at  least  soon  after  birth,  and  that  there  is  consequently  a  con- 
genital syphilis.  But  it  may  also  be  considered  as  a  fact  that 
there  is  a  "late  congenital  syphilis,"1  a  form  of  the  disease  the 
symptoms  of  which  do  not  become  apparent  until  perhaps  many 


*A  restriction  follows  later  on. 


CONGENITAL  AND  INHERITED  DISEASES     39 

years  afterwards,  though  its  cause  must  have  been  latently 
present  in  the  body  of  the  sufferer  from  the  time  of  his  birth. 
The  syphilitic  infection  is  in  such  cases  necessarily  congenital 
and  the  disease  itself  which  is  sometimes,  though  not  with  cer- 
tainty, recognisable,  was  either  present  at  birth  (latent  syphilis) 
or  at  least  prepared  (latent  syphilitic  infection).  The  same 
thing  may  happen  with  respect  to  obesity,  giant  growth, 
gout,  etc. 

What  is  not  inherited. — What  is  to  be  regarded  as 
inherited  in  these  congenital  phenomena  ?  Surely  not  that  which 
has  arisen  in  consequence  of  disease  in  the  foetus  (f.  i.  intesti- 
nal obstruction  due  to  a  cicatrix  following  an  intussusception) 
or  through  abnormalities  in  the  ovum  (such  as  constrictions  or 
amputations  by  amniotic  bands  or  coils  of  the  funis,  growth 
into  the  placenta,  etc.)  ;  as  for  these  conditions  the  maternal 
organism  has  no  direct  responsibility.  Nor  can  we  regard  as 
inherited,  anomalies  in  which  the  uterus  is  secondarily  involved, 
as  for  instance  foetal  deformities  resulting  from  pressure  pro- 
duced by  deficiency  of  liquor  amnii.  But  I  go  further  still,  and 
maintain  that  what  the  foetus  receives  from  its  mother  in  the 
course  of  its  development  is  not  inherited,  because  the  essence 
of  heredity  does  not  consist  of  the  circumstance  that  the 
descendants  have  obtained  a  particular  peculiarity  from  their 
ascendants  or  that  a  disease  has  been  transmitted  to  them  by 
their  parents  or  even  their  ancestors.  If  a  hitherto  healthy 
child  is  through  kissing  or  in  any  other  way  infected  with 
syphilis  by  its  parents  nobody  would  think  of  calling  this  heredi- 
tary syphilis  any  more  than  he  would  consider  as  hereditary 
tuberculosis  a  case  where  a  child  born  free  from  this  disease 
becomes  tuberculous  through  his  parents,  grandparents  or  any 
other  relatives.  If  a  mother  transmits  at  any  time  during  her 
life  some  acute  infectious  disease  to  her  child  nobody  ever 
thinks  of  mentioning  the  word  "inherited,"  yet  why  should  it 
be  otherwise  when  the  transmission  has  taken  place  not  during 
extra-uterine  but  during  intra-uterine  life? 

Placental  infection. — There  can  surely  be  no  differ- 
ence in  the  essence  of  the  process  because  the  placenta  has  played 
an  intermediate  part,  that  is,  because  the  infection  is  a  placental 


40  HEALTH,  DISEASE,  MARRIAGE 

one.  Whether  it  is  through  the  milk  that  a  mother  conveys 
morphia  to  her  nursling,  whether  it  is  through  a  tuberculous 
udder  that  a  cow  conveys  tubercle  bacilli  to  her  calf  or  whether 
that  conveyance  takes  place  through  the  blood  of  the  placenta, 
it  cannot  make  any  appreciable  difference.  And  if  any  one  holds 
the  extraordinary  opinion  that  conveyance  through  the  milk 
is  an  hereditary  transmission,  what  about  the  milk  of  a  tuber- 
culous cow  that  infects  with  tuberculosis  not  her  own  calf  but 
a  strange  one  or  a  human  suckling?  The  essence  of  infection 
cannot  be  any  different  if  under  exactly  similar  circumstances 
it  attacks  different  individuals.  But  if  conveyance  through  the 
milk  cannot  be  called  hereditary  transmission  why  should  we 
speak  of  such  when  the  conveyance  takes  place  through  the 
blood?  Such  a  conveyance  as  Lubarsch  rightly  says  is  only 
a  special  kind  of  metastasis,  a  metastasis  in  another  individual, 
but  in  reality  nothing  more  than  what  takes  place  when  an 
infective  agent  is  transmitted  fom  one  individual  to  another  by 
injection  into  the  blood.  Where  have  we  here  a  hereditary 
transmission?  And  how  about  infection  during  labour?  How 
far  does  heredity  go  and  where  does  acquisition  begin? 

There  are,  to  begin  with,  general  biological  reasons  why 
we  should  not  consider  as  hereditary  all  that  is  derived  from 
the  mother  during  intra-uterine  life.  In  the  amphigonous 
propagation  of  the  species  the  value  of  the  male  germ  is  for 
hereditary  purposes  equal  to  that  of  the  female,  for  we  see  how 
anxiously — if  we  may  use  such  a  term — nature  looks  to  it  that 
at  the  fecundation  of  the  ovum  the  future  new  creature  shall 
receive  just  as  much  chromatin  from  the  paternal  as  from  the 
maternal  germ.  Though  it  is  not  by  any  means  proved  as  yet 
that  the  chromatin  is  in  any  way  the  carrier  of  heredity  its 
behaviour  gives  us  a  sure  indication  as  to  the  general  nature 
of  the  paternal  and  maternal  potency,  of  the  paternal  and 
maternal  inheritance.  Were  we  to  admit  post-conceptional  influ- 
ence on  heredity  on  the  part  of  the  mother  the  value  of  the 
maternal  progenitor  with  regard  to  heredity  would  be  quite 
different  from  that  of  the  paternal;  in  such  case  the  mother 
would  be  capable  of  transmitting  hereditarily  much  more  than 
the  father.  In  any  case  this  could  happen  only  in  viviparous 


CONGENITAL  AND  INHERITED  DISEASES     41 

animals,  and  particularly  in  mammals,  and  not  even  in  all  of 
these  to  the  same  extent  because  in  aplacentals  the  conditions 
are  entirely  different  than  in  placentals.  If  in  the  discharged 
egg  of  an  animal  changes  take  place  in  the  developing  embryo 
owing  to  external  influences,  it  is  perfectly  clear  that  we  have 
before  us  not  inherited  but  acquired  conditions, — is  there  any 
material  difference  if  the  same  changes  occur  in  an  egg  while 
it  happens  as  yet  to  be  situated  inside  the  genital  organs  of  the 
mother?  Tubercle  bacilli  have  been  introduced  into  hens'  eggs 
and  tuberculosis  thereby  produced  in  the  chicks — this  is  surely 
no  inherited  tuberculosis;  and  wherein  does  the  difference  lie 
if  tubercle  bacilli,  the  syphilitic  poison  or  other  causes  of  dis- 
ease are  transferred  from  the  mother  through  the  placenta  to 
a  human  embryo  before  its  full  development?  We  have  no 
more  right  in  such  cases  to  speak  of  inherited  tuberculosis  or 
inherited  syphilis  than  in  the  above-mentioned  experiments  on 
chickens. 

And  how  about  those  animals  which  are  oviparous  as  well 
as  viviparous?  Is  in  their  case  the  possibility  of  hereditary  trans- 
mission a  variable  one,  that  is  smaller  in  the  offspring  dis- 
charged with  the  egg  and  greater  or  more  lasting  in  those  that 
are  born  in  an  advanced  state  of  development?  No,  all  that 
the  offspring  receives  in  the  course  of  its  development  after  con- 
ception is  acquired  and  not  inherited,  no  matter  at  what  period 
received,  whether  intra-uterine  or  extra-uterine,  no  matter  in 
which  way,  whether  through  the  blood,  through  the  milk  or 
otherwise. 

What  is  acquired. — Everything  is  acquired  that  arises 
through  the  influence  of  external  agencies  on  the  developing  or 
fully  developed  individual,  and  for  the  foetus  in  its  mother's 
womb  every  agency  is  external  that  proceeds  from  without  it, 
whether  it  be  situated  within  the  maternal  body  or  outside 
of  it.  The  foetus  is  in  this  respect  not  a  part  of  its  mother's 
viscera,  but  an  independent  being  possessing  its  own  life  from 
the  very  beginning.  A  white  woman  with  child  by  a  negro 
carries  in  her  womb  a  mulatto  foetus  which  can  be  no  portion 
of  the  maternal  body  as  it  is  not  possible  for  a  white  person 
under  normal  circumstances  to  have  one  part  of  herself  so 


42  HEALTH,  DISEASE,  MARRIAGE 

different  in  racial  type  as  a  mulatto  foetus  is  from  a  pure  white. 
We  therefore  arrive  at  the  following  conclusion:  All  that  an 
offspring  receives  from  its  parents  after  conception  is  acquired; 
whatever  it  receives  after  birth  is  an  extra-uterine  acquisition, 
and  that  received  during  its  sojourn  in  the  uterus  an  intra- 
uterine  one;  the  latter  being  present  at  birth  is  consequently 
congenital,  but  it  has  in  a  scientific  sense  absolutely  nothing  to 
do  with  heredity. 

What  is  inherited. — What  has  just  been  said  practi- 
cally includes  what  we  understand  by  "inherited,"  for  there  is 
only  one  meaning  possible;  only  that  may  be  regarded  as  inher- 
ited which  has  been  imparted  to  the  offspring  through  the 
germinal  cells.  This  applies  to  normal  as  well  as  to  pathological 
heredity.  It  is  true  that  pathological  heredity  presents  some 
peculiarities  and  points  which  do  not  arise  in  normal  heredity, 
but  on  the  whole  there  can  possibly  be  no  difference  between 
them.  To  call  one  kind  of  heredity  biological  and  the  other 
pathological  is  in  so  far  incorrect  as  pathology  also  is  biology, 
and  as  the  general  biological  principles  apply  to  patho- 
logical processes  the  same  as  to  normal.  But  the  most  impor- 
tant biological  principle  as  regards  heredity  is  that  the  offspring 
derive  their  inheritance  from  their  ascendants  through  the 
germinal  cells. 

As  to  the  parts  played  by  the  chromatin  substance,  by 
the  nucleus  as  a  whole,  or  by  the  cellular  body,  these  are  special 
questions  into  which  I  cannot  enter  here  particularly  as  they  and 
similar  others  are  still  awaiting  final  solution.  For  our  present 
purposes  it  is  quite  sufficient  to  state  that  the  bearers  of  heredity 
cannot  possibly  be  situated  outside  the  germ-cells  but  only  in 
their  interior,  that  they  are  firmly  bound  to  the  molecular  con- 
stituents of  the  germ-cells  with  whose  internal  structure  they  are 
most  closely  connected.  The  substance  which  is  the  bearer  of  the 
inheritance  has  been  designated  as  idioplasma  or  germ-plasma 
— the  latter  expression  introduced  by  JPeissmann1  is  the  one 
mostly  in  use — and  we  can  therefore  formulate  the  maxim  with 
regard  to  heredity,  also  as  follows:  Only  through  the  germ- 


1lVeissmann,  Ges.  Aufs.  iiber  Vererbung.    1902. 


CONGENITAL  AND  INHERITED  DISEASES    43 

plasma  does  a  descendant  inherit  from  an  ascendant,  only  that 
which  has  passed  to  the  descendant  through  the  germ-plasma 
can  be  regarded  as  inherited. 

Germinal  infection  is  not  heredity.  —  Conse- 
quently there  can  be  no  question  of  heredity  when  the  new 
individual  receives  something  which  has  been  introduced 
accidentally  by  the  germ-cells,  if  f.  i.  a  spermatozoon  enters 
into  the  ovum  which  it  impregnates,  or  in  other  words  into  the 
future  embryo,  accompanied  by  a  tubercle  bacillus.  It  is  imma- 
terial whether  the  bacillus  adheres  to  the  exterior  of  the  sper- 
matozoon or  whether  it  lies  in  its  interior,  if  there  is  room,  pro- 
vided that  the  molecular  structure  of  the  spermatozoon,  that 
is  the  germ-plasma,  has  undergone  no  important  change.  Such 
cases  have  been  spoken  of  as  hereditary  tuberculosis  of  the 
foetus,  but  without  any  justification,  as  the  germ-cells  have  not 
produced  the  tuberculosis;  they  were  merely  the  accidental  car- 
riers of  the  infective  virus.  We  may  therefore  speak  in  such  a 
case  of  a  germinal  infection,  as  opposed  to  the  placental  infec- 
tion discussed  above,  but  this  can  never  be  an  inherited  tubercu- 
losis; we  might  at  the  utmost  speak  of  pseudo-heredity.  The 
best  illustration  of  this  is  furnished  by  Friedmann's1  experi- 
ments on  germinal  tuberculous  infection  in  rabbits.  By  inject- 
ing immediately  after  the  copulation  of  two  healthy  animals  a 
broth  of  artificially  cultivated  tubercle  bacilli  into  the  vagina 
of  the  female  animal,  so  that  it  became  mixed  with  the  seminal 
fluid,  he  succeeded  in  finding  tubercle  bacilli  in  the  embryos  of 
the  first  week,  especially  of  the  sixth  day2,  but  only  in  them  and 
not  in  the  maternal  body.  And  though  tuberculosis  could  not 
be  shown  to  exist3  there  was  the  beginning  of  it,  an  infection 
with  tubercle  bacilli,  and  no  one  will  doubt  that  it  came  into 
the  ovulum,  and  thus  into  the  embryo,  along  with  a  spermato- 
zoon. We  may  therefore  speak  of  a  tuberculous  infection 
produced  by  germ-cells,  but  would  it  occur  to  any  one  to  call 
this  an  hereditary  infection  or  hereditary  tuberculosis,  should 


1F.  F.  Friedmann,  Exper.   Stud,  tiber  die  Erblichkeit  der  Tuberkulose. 
Zeitschr.  f.  Klin.  Med.   Vol.  43,  p.  ii.  1901. 
'Later  also,  as  I  am  informed. 
§I  am  informed  that  subsequently  there  were  also  none. 


44  HEALTH,  DISEASE,  MARRIAGE 

the  foetuses  really  become  tuberculous,  that  is  develop  tubercu- 
losis, although  there  was  nothing  tuberculous  to  inherit  from 
the  parent  animals?  And  would  it  be  any  different  if  the  tubercle 
bacilli  were  not  added  artificially  to  the  spermatic  fluid  but  came 
from  the  same  organism  as  the  latter?  Certainly  not.  There  is  just 
as  little  heredity  in  the  one  case  as  in  the  other  and  if  a  human 
foetus  were  to  receive  from  its  father  an  infective  virus  along 
with  the  spermatozoon  this  would  no  doubt  constitute  a  ger- 
minal infection,  and  if  the  child  is  born  infected,  a  congenital 
infection,  but  as  to  heredity  the  whole  process  would  have  abso- 
lutely nothing  to  do  with  it.  And  what  has  been  said  with 
respect  to  the  paternal  germ-cell  applies  equally  to  the  maternal 
one,  the  ovum.  Only  when  the  germ-cells  have  undergone  an 
alteration  in  their  internal  construction,  in  their  composition  or 
perhaps  only  in  their  chemical  constitution,  if  new  peculiar  con- 
ditions arise  thereby  in  the  body  of  the  new  individual — which 
Weissmann  rightly  designates  as  the  soma,  in  contra-distinction 
to  the  germ-plasma,  the  bearer  of  heredity  which  as  we  have 
seen  is  contained  only  in  the  sexual  or  germinal  cells — it  is  only 
then  that  we  can  speak  of  hereditary  phenomena. 

The  meaning  of  disease  and  predisposition 
to  disease. — I  will  now  attempt  to  explain  the  meaning  of 
the  words  "disease,"  "tendency  to  disease"  or  as  it  is  usually 
called  "predisposition  to  disease,"  and  this  I  can  do  very  briefly. 
Disease  is  a  process,  a  vital  process,  but  one  deviating  from 
the  normal  and  showing  signs  of  injury;  disease  is  life,  but  life 
under  abnormal  conditions  and  with  abnormal  aspects;  where 
there  is  no  life  there  can  also  be  no  disease,  where  there  is  no 
disturbance  of  vital  processes  showing  signs  of  injury,  there  is 
also  no  disease.  The  external  cause  of  a  disease  as  f.  i.  parasites 
may  be  present,  there  may  be  an  infection,  but  an  infectious 
disease  as  a  consequence  of  that  infection1  does  not  begin  until 
the  parasites  occasion  disorder  in  the  vital  processes,  until  the 
latter  are  injuriously  disturbed.  It  is  absolutely  necessary  to 


lSerious  misunderstandings  are  apt  to  arise  if,  as  it  is  often  done,  no 
sharp  distinction  is  made  between  infection  and  infectious  disease,  and  if 
the  disease  as  such  is  also  called  infection.  The  latter  term  in  reality  only 
means  "contamination." 


AND  INHERITED  DISEASES     45 

distinguish  between  the  notions  "cause  of  disease,"  "parasites" 
and  "disease."  A  man  may  harbour  in  his  mouth  virulent 
diphtheria  bacilli  without  being  ill;  he  has  no  diphtheria,  he 
is  not  diphtheritic,  although  he  carries  about  with  him  the 
causative  agent  of  diphtheria  and  although  he  can  make  others 
diphtheritic  by  conveying  to  them  those  causative  agents.  The 
rabbit-embryos  of  Friedmann  contained  tubercle  bacilli  but  they 
were  not  tuberculous  as  there  were  no  demonstrable  signs  what- 
ever of  disordered  vitality,  no  morphological  changes  and  no 
disturbances  of  development.  If  there  has  been  in  any  particular 
case  a  congenital  transmission  of  the  cause  of  a  disease  we  are 
not  justified  in  speaking  of  a  congenital  disease  as  long  as  there 
are  no  demonstrable  morbid  disorders  of  vitality.  We  can  only 
speak  of  a  congenital  infection,  because  in  my  opinion  infection 
begins  with  the  transmission  of  active  and  living  parasites.  It 
is  true  that  the  usual  form  of  speech  does  not  in  cases  where  a 
disease  springs  from  an  infection  differentiate  very  accurately; 
we  speak  f.  i.  of  a  late  congenital  syphilis  though  in  reality 
this  is  not  quite  correct  as  the  syphilis  as  such,  that  is  the  dis- 
ease with  all  its  symptoms  is  not  present,  or  at  least  not  notice- 
able at  birth  and  as  nothing  but  the  cause  of  the  disease  is 
latently  inherent.  The  circumstances  are  here  totally  differ- 
ent than  in  the  case  f.  i.  of  the  secondary  sexual  characters, 
because  these  are  already  formed  at  birth,  whereas  of  the  dis- 
ease there  is  nothing  present  and  its  commencement  dates  from 
a  subsequent  period. 

As  to  what  is  to  be  understood  by  tendency  to  disease  or 
predisposition  to  disease,  opinion  is  very  much  divided.  This 
is  evidenced  by  the  literature  on  the  subject.  In  my  judgment 
it  ought  to  be  taken  for  granted  that  what  comes  here  into  ques- 
tion are  bodily  conditions,  the  peculiarities  of  the  build,  of  the 
chemical  composition  and  of  the  activity  of  the  organic  tissues 
and  the  qualities  of  the  individual  constitution. 

The  human  body  is  not  without  protection  at  the  mercy  of 
external  causes  of  disease  and  particularly  at  that  of  parasites; 
on  the  contrary  it  possesses  quite  a  large  number  of  protective 
agencies  partly  morphological  and  partly  biological  which, 
being  to  a  great  extent  regulating  arrangements,  enable  it  to 


46  HEALTH,  DISEASE,  MARRIAGE 

offer  resistance  to  abnormal  conditions  of  life  and  to  external 
causes  of  disease  the  tendency  of  which  is  to  generate  disorder 
in  the  vital  processes,  viz. :  to  produce  a  disease ;  they  enable 
it  to  render  those  causes  abortive  and  thereby  maintain  the 
normal  course  of  the  process  of  life.  Everything  which  pre- 
vents that  regulation  from  taking  place,  every  incapacity  of  the 
body  to  resist  external  causes  of  disease,  therefore,  every 
peculiarity  of  the  constitution  which  renders  the  latter  unable 
in  the  struggle  of  the  body  with  the  causes  of  disease  to  main- 
tain the  normal  course  of  the  vital  phenomena,  every  such 
peculiarity  of  the  constitution  may  be  designated  as  a  tendency, 
as  a  predisposition  to  disease.  There  need  not  in  this  connection 
be  any  deviation  of  individual  constitutions  from  the  type  of 
constitution  of  human  beings  as  a  class,  there  may  be  also  typical 
general  characteristics  of  constitution  which  though  normal  in 
themselves  may  represent  dispositions  to  disease  in  so  far  as 
they  tend  to  favour  the  origination  of  some  particular  disease 
or  in  so  far  as  they  are  not  capable  of  preventing  that  origi- 
nation. Such  are  the  predispositions  to  disease  which  appertain 
to  the  human  body  as  opposed  to  the  bodies  of  animals;  such 
the  predispositions  by  which  various  groups  of  humanity  are 
distinguishable  in  a  regulated  manner  from  one  another  accord- 
ing to  age,  sex  or  race.  All  these  predispositions  to  disease  must 
be  congenital  and  inherited,  for  they  are  a  result  of  the  phylo- 
genetic  development,  they  have  their  origin  in  the  general 
characters  inherent  in  the  germ-cells. 

There  is  however  a  difference  as  regards  those  peculiarities 
of  constitution  by  which  an  individual  distinguishes  himself 
from  the  type  of  man  in  his  normal  state,  which  belong  to  him 
personally  and  which  constitute  his  own  individual  personality. 
These  are  individual  predispositions  to  disease  which  we  desig- 
nate as  family  predispositions  when  the  same  special  peculiari- 
ties of  constitution  appear  in  several  members  of  one  and  the 
same  family.  Of  course  not  all  individual  peculiarities  of  body, 
not  all  family  peculiarities  of  body,  are  predispositions  to  dis- 
ease ;  they  are  so  only  in  so  far  as  they  do  not  prevent  the  pro- 
duction of  disease  or  in  so  far  as  they  tend  to  favour  it. 

This  conception  of  what  constitutes  predisposition  to  disease 


CONGENITAL  AND  INHERITED  DISEASES    47 

does  not  contain  anything  mystical;  it  is  not  beyond  the  domain 
of  science,  and  is  just  as  capable  of  scientific  treatment  as  any 
other  pathogenetic  question,  though  we  must  admit  that  our 
knowledge  of  the  predispositions  to  disease  does  not  go  much 
beyond  a  few  generalities. 

Congenital  and  inherited  diseases. — In  coming 
now  to  the  general  answer  to  the  question  whether  there  are 
congenital  diseases  and  how  much  heredity  has  to  do  with  them, 
it  is  not  necessary  for  me  to  mention  that  there  are  such  dis- 
eases, as  this  is  so  well  known.  I  only  wish  to  point  out  again 
that  strictly  speaking  we  can  call  a  disease  congenital  only  if 
the  disturbance  of  the  vital  processes  which  constitutes  the 
nature  of  the  disease  was  already  present  at  birth.  If  that  dis- 
turbance appears  later  it  was  obviously  not  present  at  birth  and 
what  was  then  present  was  at  the  utmost  its  cause  only.  But 
the  cause  of  a  disease  and  the  disease  itself — this  cannot  be 
emphasised  too  much  and  too  often — are  not  one  and  the  same 
thing.  In  the  majority  of  cases  it  is  congenital  infectious  dis- 
eases that  we  meet,  anthrax,  pneumonia,  relapsing  fever,  sepsis, 
typhus,  small-pox,  syphilis,  tuberculosis  (rarely),  leprosy, 
cholera  (presumably),  articular  rheumatism,  malaria,  measles, 
scarlet  fever,  but  there  may  also  be  foetal  diseases  of  another 
kind.  By  far  the  greatest  number  of  all  foetal  diseases,  what- 
ever their  nature  may  be,  make  their  appearance  only  during 
the  development  of  the  foetus  in  the  earlier  or  later  months  of 
pregnancy;  an  hereditary  transmission  of  the  disease  is  there- 
fore out  of  the  question.  But  it  is  highly  probable  that  even 
in  those  congenital  diseases  which  are  of  germinal  origin, 
heredity,  in  a  scientific  sense,  must,  after  what  has  been  said 
above,  be  excluded,  inasmuch  as  it  is  almost  exclusively  infec- 
tious diseases  that  come  into  consideration.  It  would  be  possi- 
ble to  speak  of  an  inherited  disease  only  where  one  or  both  of 
the  germ-cells  were  specifically  diseased,  but  this  is  hardly  likely 
ever  to  occur  in  practice  seeing  how  improbable  it  is  that  dis- 
eased germ-cells  could  give  life  to  a  regularly  developing 
embryo.  Nevertheless  the  further  evolution  of  an  embryonic* 
structure  emanating  from  a  diseased  germ-cell  is  not  altogether 
impossible,  and  it  is  quite  conceivable  that  the  general  ill- 


48  HEALTH,  DISEASE,  MARRIAGE 

development,  the  general  want  of  vitality,  the  dystrophy  so 
frequently  observed  among  the  offspring  of  syphilitic  parents, 
may  be  due  to  the  fact  that  the  germ-cells  were  somewhat 
damaged  and  to  a  certain  extent  affected  with  syphilis.  But 
such  a  conclusion  is  by  no  means  necessary  as  all  these  conditions 
might  very  well  have  been  produced  at  a  later  stage  in  the 
foetal  body  by  toxins  arising  from  the  syphilitic  virus.  The 
observation  that  the  danger  of  transmitting  syphilis  to  the 
embryo  is  greater  in  proportion  to  the  acuteness  of  the  symptoms 
in  the  parents,  may  be  explained  either  by  a  gradually  diminish- 
ing injurious  effect  on  the  germ-cells  or  by  a  gradually  dimin- 
ishing virulence  of  the  infective  virus. 

We  may  therefore  draw  the  inference  that  undoubtedly  by 
far  the  greatest  number  of  congenital  diseases  are  not  hereditary 
and  that  in  all  probability  there  are  no  hereditary  diseases  at 
all.  As  regards  especially  the  most  important  diseases  namely 
those  due  to  infection  there  are  no  doubt  congenital  infectious 
diseases  produced  by  placental — now  and  then  also  perhaps  by 
germinal — infection,  but  no  such  hereditary  diseases. 

Congenital  and  inherited  predispositions  to 
disease. — The  conditions  are  totally  different  as  regards  the 
predispositions  to  disease.  The  general  ones  do  not  of  course 
concern  us  here;  we  have  to  consider  only  the  individual  and 
the  family  predispositions.  As  we  are  not  thoroughly  familiar 
with  the  finer  conditions,  morphological  as  well  as  biologico- 
chemical  of  those  constitutional  peculiarities  which  must  be 
regarded  as  the*  principal  predispositions  to  disease  and  which 
may  either  date  from  the  first  stages  of  the  embryonic  structure 
(dispersed  germ-cells,  incomplete  differentiation,  etc.),  or  arise 
at  a  subsequent  period  of  the  development,  we  are  not  generally 
in  a  position  to  demonstrate  them  objectively  but  must  infer  them 
chiefly  from  their  results  and  from  their  action;  and  such  infer- 
ences must  always  be  treated  with  the  greatest  discrimination. 
Here  we  are,  however,  often  confronted  with  the  difficulty  that 
it  is  not  always  by  any  means  quite  clear  what  is  to  be  regarded 
as  cause  and  what  as  effect,  what  as  predisposition  to  disease, 
and  what  as  a  consequence  of  disease.  In  no  other  disease  is  this 
difficulty  so  markedly  apparent  as  in  tuberculosis. 


CONGENITAL  AND  INHERITED  DISEASES     49 

Hereditary  predisposition   to   tuberculosis.— 

Heredity  has  always  been  supposed  to  play  an  important  part 
in  this  disease,  and — particularly  since  the  discovery  of  the 
tuberculous  virus  and  the  recognition  of  its  bacillary  nature — 
numerous  pathologists  and  physicians  have  attached  very  great 
value  to  a  congenital  and  hereditary  predisposition  to  it.  It  was 
at  first  believed  that  that  disposition  lay  in  the  so-called 
scrofulous  constitution,  but  this  opinion  proved  to  be  to  a  great 
extent  erroneous,  as  it  has  been  shown  that  much  (perhaps  all?) 
of  what  was  designated  as  "scrofulous"  is  nothing  but  a  tuber- 
culous process.  But  are  we  justified  in  denying  all  congenital 
general  predisposition  to  tuberculosis?  That  germinal  trans- 
mission of  tubercle  bacilli,  in  other  words  a  pseudo-heredity, 
plays  any  important  part  at  all  is  admitted  by  few  pathologists ; 
most  of  them  attach  the  greatest  weight  to  extra-uterine  infec- 
tion and  there  is  no  doubt  that  much  of  the  hereditary  aspect 
of  tuberculosis  is  due  to  the  circumstance  that  ascendants  con- 
stantly infect  their  descendants  and  that  as  a  consequence  of 
this  infection  several  successive  generations  of  the  same  family 
are  attacked  by  tuberculosis.  On  the  other  hand  if  we  bear  in 
mind  how  very  prevalent  tuberculosis  is,  and  that  it  is  hardly 
possible  for  any  one  to  avoid  exposing  himself  repeatedly  to 
the  danger  of  infection,  if  we  consider  how  many  individuals 
carry  in  their  bodies  traces  of  tuberculous  disease  without  suffer- 
ing from  severe  local  or  general  tuberculosis,  we  cannot  refuse 
to  recognise  that  in  those  individuals  who  do  suffer  severely 
from  the  disease,  and  particularly  in  those  frequent  cases  where 
at  certain  periods  of  development,  during  puberty,  tuberculosis 
makes  such  rapid  progress  and  is  so  soon  fatal,  there  must  be 
some  other  general  constitutional  peculiarities  playing  an  impor- 
tant part,  the  more  so  as  often  enough  the  tuberculous  parent 
dies  at  an  early  age  and  there  is  consequently  no  continuous 
family  infection  present  at  all.  We  are  thus  impelled  to  think 
of  the  variable  general  susceptibility  of  different  animals,  to 
remember  that  even  among  animals  of  the  same  class  there 
are  different  races  with  different  susceptibilities,  that  among 
animals  also  there  are  doubtless  individual  differences  of  suscep- 
tibility, and  therefore  an  individual  predisposition  of  a  general 


50  HEALTH,  DISEASE,  MARRIAGE 

kind  to  tuberculosis.  From  this  we  must  further  conclude  that 
in  man  as  well  there  is  latent  a  general  predisposition  to  tuber- 
culosis, and  that  in  many  family-tuberculoses  this  predisposition 
is  inherited;  and  I  see  no  objection  to  this  same  general  pre- 
disposition being  called  by  the  name  of  "scrofula." 

But  there  are  in  tuberculosis,  besides  the  general,  also  local 
constitutional  peculiarities,  and  with  regard  to  these  the  same 
question  arises,  viz. :  how  far  are  they  to  be  considered  as  conse- 
quences of  the  disease  and  how  far  as  primary  congenital  pre- 
dispositions to  disease. 

That  many  tuberculous  individuals — this  is  especially 
noticeable  in  early  youth — are  narrow-chested  and  charac- 
terised by  a  contracted  and  flat  thorax  is  an  undisputed  fact; 
but  whether  this  so-called  phthisical  thorax  was  present  previ- 
ous to  the  tuberculosis,  or  whether  it  is  a  consequence  of  pre- 
ceding tuberculous  changes  in  the  thoracic  organs,  these  are 
questions  upon  which  opinions  are  still  very  much  at  variance. 
If,  as  I  consider  it  to  be  correct,  the  thoracic  malformation  is 
the  primary  event  and  something  congenital,  may  it  not  have 
arisen  because  some  phthisical  ancestor  acquired  such  a  thorax, 
and  because  this  acquired  new  condition  was  inherited  as  a  pre- 
disposition to  phthisis?  Is  there  such  a  correlation  between  the 
bones  of  the  thorax  and  the  germ-cells  that  the  alteration  pro- 
duced by  disease  in  the  former  is  to  a  certain  extent  reflected 
in  the  latter? 

The  discussion,  started  some  time  ago  by  Freund,  and 
recently  resumed,  as  to  the  significance  of  a  special  shape  of  the 
upper  aperture  of  the  thorax,  and  particularly  as  to  the  length 
and  situation  of  the  first  rib,  in  connection  with  the  origin  of 
tuberculosis  in  the  apices  of  the  lungs  will,  to  my  mind,  have 
to  end  with  a  general  admission  that  the  condition  is  certainly 
not  a  consequence  of  existing  tuberculosis,  but  a  congenital  pri- 
mary predisposition  to  apical  phthisis.  But  who  dares  to  decide 
whether  the  special  shape  of  the  first  rib  owes  its  existence  to 
some  primary  germinal  variation  due  to  some  cause  or  other, 
or  whether  it  represents  a  primary  somatic  variation?  There 
can  be  no  doubt  as  to  the  primary  nature  of  the  predisposition  in 
those  cases  in  which  a  congenital  narrowness  of  the  pulmonary 


CONGENITAL  AND  INHERITED  DISEASES     51 

artery  has  been  the  basis  of  a  tuberculosis  of  the  lungs;  we  may 
here  safely  admit  that  the  severe  congenital  anomaly  has 
favoured  the  production  of  the  subsequent  disease. 

Other  congenital  manifestations  of  disease. — 

We  can  find  many  other  similar  examples,  as  for  instance  the 
frequency  of  morbid  changes  in  retained  testicles  or  in  other 
organs  in  an  abnormal  state  of  development.  We  may  also  call 
attention  to  the  physical  so-called  signs  of  degeneration  in  indi- 
viduals affected  with  an  hereditary  predisposition  to  mental  dis- 
orders. These  signs  of  degeneration  are  at  least  in  part,  prob- 
ably secondary  phenomena  only,  consequences  of  the  altruism 
prevailing  in  the  body  as  a  whole,  or,  as  Roux  says,  of  the 
struggle  between  parts  of  the  body,  the  effect  of  which  is  that 
changes  in  one  part  cause  disturbances  in  other  parts  also — but 
they  are  nevertheless  visible  signs  of  an  alteration  in  the  con- 
stitution. 

In  numerous  cases  where  family  diseases,  and  especially 
also  metabolic  disorders,  are  present  (congenital  obesity,  gout, 
diabetes,  etc.),  we  have  hardly  any  indications  as  yet  of  the 
hereditary  constitutional  abnormalities  upon  which  they  are 
based  and  which  produce  the  predispositions  to  them.  We  know 
just  as  little  with  regard  to  those  predispositions  which  rest  on 
non-inherited  disorders  of  development,  as  for  instance  tumours, 
for  the  causes  of  which  many  pathologists  look  in  such  processes 
as  germinal  misplacements,  etc.  It  must  therefore  be  the  object 
of  science  to  find  out  by  careful  research  which  deviations  in 
the  structure  and  chemical  composition  of  the  human  body 
should  be  considered  as  congenital  foundations  of  predispositions 
to  disease.  It  is  well,  in  this  connection,  to  remember  that  it 
is  not  necessary  for  even  the  congenital  constitutional  peculiari- 
ties, that  is  the  predispositions  to  disease,  to  be  quite  complete 
at  birth;  they  may  become  so  at  a  later  period  of  development. 
Vice-versa,  not  every  pathological  condition  in  young  children 
(smallness,  atrophy,  dystrophy,  anaemia,  etc.)  must  be  regarded 
as  congenital,  inasmuch  as  unfavourable  external  circumstances 
are  in  themselves  sufficient  to  produce  such  abnormalities.  Only 
when  we  shall  have  become  familiar  with  th'e  exact  morpho- 
logical principles,  it  will  be  possible  to  attempt  an  answer  to 


52  HEALTH,  DISEASE,  MARRIAGE 

the  second  question  with  better  prospects  of  success  than  we 
have  at  present,  only  then  we  shall  be  able  to  say  how  far  such 
congenital  predispositions  to  disease  may  be  regarded  as  inher- 
ited, and  how  far  the  hereditary  transmission  of  acquired 
peculiarities  comes  here  into  question. 

Hereditary  transmission  of  anomalies  and 
malformations. — That  particular  physical  peculiarities  may 
be  transmitted  hereditarily  is  amply  demonstrated  by  certain 
anomalies  and  malformations.  Though  they  are  not  necessarily 
diseases  or  predispositions  to  disease  they  are  nevertheless 
pathological  conditions,  deviations  from  the  normal  build  of  the 
human  body,  which  we  cannot  here  leave  unnoticed,  as  they  are 
typical  of  the  proper  predispositions  to  disease. 

If  we  hear  for  instance  that  hexadactylism  has  been  present 
through  several  generations,  that  a  whole  village  (Eycaux, 
here)1  in  which  the  inhabitants  have  intermarried  for  a  long 
time  consisted  finally  almost  entirely  of  six-fingered  individuals 
and  that  the  anomaly  commenced  to  disappear  as  soon  as  mar- 
riages with  outsiders  became  more  frequent,  thus  introducing 
fresh  germ-plasms,  we  are  obliged  to  admit  that  the  case  must 
be  one  of  inherited  anomaly  though  the  possibility  is  not  alto- 
gether precluded  that  there  were  also  other  factors  concerned 
which  must  necessarily  have  been  present  when  the  anomaly 
occurred  for  the  first  time. 

In  the  case  of  hexadactylism,  the  anomaly  has  been  referred 
to  as  an  atavistic  phenomenon,2  though  as  Gegenbauer  has 
shown,  quite  unjustly,  but  even  if  it  were  so,  there  must  also  have 
been  some  special  reason  why  the  reaction  occurred  in  one 
particular  individual.  Besides,  similar  conditions  as  in  poly- 
dactylism  occur  also  in  syndactylisrn,  peromelia,  daltonism, 
and  other  anomalies,  in  which  an  atavistic  explanation  is  out 
of  the  question  and  as  to  which  we  may  say  with  certainty  that 
the  persons  who  showed  these  malformations  first  did  not 
inherit  them;  the  anomalies  must  consequently  have  been  pro- 
duced by  other  circumstances  and  these  same  circumstances 


1F.  Devay,  Du  Danger  des  mariages  consanguins,  1862.  ref.  Arch.  gen. 
de  med.  1863.  I  p.  763. 

*For  details  see  further  on. 


CONGENITAL  AND  INHERITED  DISEASES     53 

could  very  well  retain  their  activity  through  subsequent  genera- 
tions. We  are  compelled  to  think  of  such  complications  in  con- 
nection with  the  remarkable  case  of  Struthers1  where  four  gen- 
erations were  required  to  produce  complete  polydactylism  (in 
the  hands  and  in  the  feet) .  In  the  first  generation  there  was  a 
sixth  finger  in  one  hand,  in  the  second  generation  in  both  hands, 
in  the  third  generation  three  brothers  had  six  fingers  to  each 
hand  and  one  of  them  in  addition  a  sixth  toe  in  one  foot,  and 
the  descendants  of  this  one,  that  is  the  fourth  generation,  had 
six  digits  to  each  hand  and  foot.  The  explanation  which  has 
been  given  of  other  cases,  in  which  there  is  an  aggravation  of 
the  peculiarity  in  the  second  generation,  and  which  appears 
quite  admissible,  is  here  not  sufficient.  It  has  been  assumed  that 
the  cause  which  produces  the  corporeal  anomaly  acts  upon  the 
germ-cells  at  the  same  time  and  in  a  more  marked  degree,  so 
that  the  descendant  emanating  from  these  germ-cells  presents 
the  same  anomaly  in  an  aggravated  form.  It  would  therefore 
be  possible  in  the  above  observation  to  account  for  the  appear- 
ance of  a  severer  polydactylism  in  the  second  generation  by 
admitting  that  the  original  cause  effected  not  only  a  somatic 
disturbance  but  also  a  specific  alteration  in  the  germ-plasma.  But 
the  progression  of  the  malformation  through  four  generations 
appears  to  be  impossible  unless  we  recognize  the  existence  of 
a  continuous,  specific  causation,  especially  as  there  was  no  heredi- 
tary predisposition  through  the  other  parent.  The  matter  is  still 
more  complicated  because  of  the  fact  that  in  this  case  like  in 
many  others,  the  malformation  was  not  by  any  means  present 
in  all  the  descendants.  We  must  therefore  be  very  careful  when 
expressing  an  opinion  on  the  hereditary  transmission  of  mal- 
formations and  abnormalities,  and  bear  in  mind  above  all  that 
occasionally,  as  I  have  already  mentioned,  such  occurrences  are 
not  the  primary  event,  but  something  secondary,  something  con- 
sequential, something  necessarily  dependent  on  a  primary  con- 
dition. Where  the  latter  is  inherited  the  consequential  result  is 
also  bound  to  make  its  appearance,  though  it  has  not  itself  been 
hereditarily  transmitted.  For  instance,  club-foot  may  appear  in 


1Struthers,  Edinb.  New  Philos.  Journal.    July  1863. 


54  HEALTH,  DISEASE,  MARRIAGE 

several  successive  generations  not  because  the  foot  deformity  is 
hereditarily  transmitted,  but  rather  the  deficiency  of  liquor  amnii 
of  which  it  is  the  consequence. 

Influence  of  the  mother  on  the  foetus. — Espe- 
cial caution  is  indicated  when  a  change,  a  new  condition,  is 
present  only  in  the  mother  and  the  child;  there  is  of  course 
nothing  hereditary  if  the  change  occurred  in  the  mother  during 
pregnancy.  It  has  been  asserted  for  instance  that  cicatricial 
changes  which  have  taken  place  in  pregnant  women  in  conse- 
quence of  injuries,  have  shown  themselves  in  analogous  posi- 
tions on  the  bodies  of  the  children  subsequently  born;  similar 
experimental  observations  have  also  been  reported.1  Of  course 
there  can  be  nothing  hereditary  in  this,  as  the  whole  process  has 
nothing  whatever  to  do  with  the  germ-cells,  and  is  at  the  most 
an  intra-uterine  transmission,  but  we  are  absolutely  at  a  loss 
to  explain  it,  inasmuch  as  the  foetal  body  was  already  moulded 
before  the  injury  to  the  mother  occurred,  and  a  communication 
could  only  have  been  possible  through  the  placenta,  which  com- 
munication we  can  only  think  of  as  one  of  a  chemical  nature. 
If  we  consider  that  in  most  of  the  cases  the  change  in  the  off- 
spring did  not  by  any  means  correspond  exactly  to  that  in  the 
mother,  and  that  there  was  only  a  change  of  some  kind,  if  we 
bear  in  mind  how  often  in  recent  times  surgical  operations  of 
various  kinds  have  been  performed  upon  pregnant  women, 
without  the  foetuses  undergoing  any  corresponding  changes,  we 
should  probably  feel  inclined  to  regard  those  rare  cases  where 
the  child  has  apparently  participated  in  the  acquisition  of  a  new 
morphological  peculiarity  on  the  part  of  the  maternal  body,  to 
attribute  them  to  accidental  coincidence  rather  than  to  estab- 
lished relationship. 

This  applies  to  an  even  greater  extent  in  those  cases  in  which 
the  maternal  body  is  not  visibly  altered,  where  the  mother  has 
received  only  mental  impressions  of  a  special  kind  or  allowed 
herself  to  be  influenced  by  the  products  of  her  imagination. 

The  "maternal  Impressions"  of  pregnant 
women. — To  the  first  group  belong  the  so-called  "maternal 


*Exner,  Sitzungsber.  d.  K.  K.  Ges.  d.  Arzte  in  Wien.    Sitzg.  vom  18 
Febr.  1887. 


CONGENITAL  AND  INHERITED  DISEASES     55 

impressions"  of  pregnant  women:  Mental  impressions,  as  a 
rule  of  a  disagreeable  and  repugnant  nature  received  by  preg- 
nant women,  are  supposed  to  be  the  cause  of  changes  in  the 
external  physical  form  of  the  children  subsequently  born,  of 
changes  similar  to  the  agencies  which  produced  the  unpleasant 
impressions  in  the  mothers ;  similar,  but  by  no  means  alike,  and 
even  the  similarity  was  in  not  a  few  of  the  reported  cases  only 
very  remote.  We  may  repeat  here  what  has  already  been  said 
on  the  correlation  between  mother  and  child  and  on  the  possi- 
bility of  influence  of  the  former  upon  the  latter;  it  is  only 
through  chemical  substances  that  such  an  influence  is  at  all 
conceivable,  but  as  to  "how"  this  influence  acts,  this  is  in  my 
opinion  quite  beyond  understanding,  particularly  because  it  is 
not  a  question  of  arrested  development  of  physical  parts,  but,  as 
a  rule  at  least,  of  atrophy  or  reaction  in  the  differentiation. 

By  far  the  greatest  number  of  cases  of  "maternal  impres- 
sions" relate  to  women  who  have  reached  the  second  half  of  the 
stage  of  pregnancy  or  at  least  a  period  when  the  body  of  the 
foetus  has  already  received  its  form.  Incomplete  formation  of 
extremities  could  therefore  at  the  most  be  caused  by  a  disappear- 
ance of  parts  already  existing;  for  hare-lip  to  be  produced  it 
would  be  necessary  that  the  definite  formation  of  the  lips  already 
completed  should  be  destroyed  and  replaced  by  a  condition  of 
an  earlier  period  of  development, — in  a  word  it  only  needs 
weighing  all  the  circumstances  of  the  case  to  come  at  once  to 
the  conclusion  that  a  direct  correlation  is  here  impossible.  The 
few  cases  in  which  the  correlation  seems  to  exist  are  noticed  and 
recorded,  others  more  numerous,  in  which  the  children  do  not 
exhibit  anything  of  a  striking  nature,  are  ignored  altogether. 

Different  to  these  influences  upon  children  in  the  course  of 
their  development,  are  the  influences  on  the  germ-cells  before 
copulation,  which  may  proceed  not  only  on  the  part  of  the 
mother,  but  also  on  that  of  the  father.  As  it  is  changes  in  the 
germ-cells  which  come  here  into  question,  it  is  possible  for  the 
new  individual  emanating  from  them  to  develop  a  new  quality 
which  is  hereditary,  seeing  that  it  is  based  upon  alterations  in 
the  germ-plasma.  But  how  do  alterations  take  place  in  the 
germ-cells,  in  the  germ-plasma  ? 


56  HEALTH,  DISEASE,  MARRIAGE 

How  do  alterations  in  the  germ-plasma  oc- 
cur?— These  also  have  been  attributed  to  mental  impres- 
sions. Von  Esmarch1  narrates  the  case  of  a  woman  who  was 
one  day  very  much  impressed  by  a  preserved  foetus  and  particu- 
larly by  its  small  lower  jaw;  the  same  evening  fruitful  copula- 
tion took  place,  and,  strange  to  say,  the  child  resulting  from 
the  same  had  in  addition  to  other  abnormalities  a  misshapen 
lower  jaw.  If  the  ripe  ovum  became  on  that  evening  impreg- 
nated, it  must  already  have  left  the  graffian  follicle,  and  conse- 
quently have  ceased  to  be  a  part  of  the  maternal  organism,  even 
if  copulation  took  place  some  little  time  afterwards.  Further 
influence  upon  it  on  the  part  of  the  maternal  body  could  there- 
fore be  exercised  only  through  chemical  action;  but  how  is  it 
possible  for  a  mental  impression  to  produce  such  a  chemical 
action  on  an  ovum  lying  freely,  say,  in  one  of  the  Fallopian 
tubes  that  the  individual  susequently  emanating  from  that  ovum 
should  exhibit  corporeal  conditions  similar  to  those  of  the 
object  which  created  the  mental  impression?  How  can  f.  i.  a 
white  woman  who  catches  sight  of  a  negro  while  she  is  copu- 
lating with  a  white  man  give  to  the  child  resulting  from  this 
copulation  a  coloured  skin  ?  There  certainly  are  many  things  in 
this  world  of  ours  which  are  beyond  the  grasp  of  our  school- 
learning;  but  where  there  is  absolutely  no  possibility  to  explain 
a  certain  alleged  fact,  we  are  surely  justified  in  demanding  first 
that  that  fact  should  be  demonstrated  without  the  shadow  of  a 
doubt.  Post  hoc  ergo  propter  hoc  is  no  admissible  proof,  and 
we  are  therefore  entitled,  for  the  present,  at  any  rate,  to  doubt 
the  fact  of  correlationship  between  mental  impressions  during 
or  shortly  before  fruitful  copulation  and  special  changes  in  the 
body  of  the  child. 

We  may  say  the  same  thing  with  reference  to  the  belief 
that  mental  representations  of  certain  real  objects,  that  is  prod- 
ucts of  the  phantasy,  during  copulation  are  capable  of  influ- 
encing decisively  the  physical  formation  of  the  begotten  child. 
The  sinful  thought  of  Edward  the  husband  and  of  Charlotte 
the  wife,  in  Goethe's  "Wahrverwantschaften,"  both  of  whom 
imagine  that  they  have  committed  adultery  with  their  respective 

V.  Esmarch-Kulenkampf,  Die  elephantiastischen  Formen.    1886. 


CONGENITAL  AND  INHERITED  DISEASES     57 

lovers  Ottilie  and  the  captain  was  really  nothing  but  fancy,  if 
the  only  proof  of  guilt  lay  in  the  circumstance  that  the  child 
resembled  in  its  facial  features  not  its  parents  but  their  lovers. 
More  within  our  comprehension  is  another  possibility, 
namely  that  changes  have  taken  place  in  the  germ-cells  during 
the  interval  between  their  discharge  and  their  copulation,  through 
the  action  of  chemical  agencies.  It  has  been  asserted,  and 
specially  by  Krafft-Ebing,1  that  otherwise  sane  and  sober  parents 
may  produce  mentally  deficient,  idiotic  or  epileptico-idiotic 
children  if  they  have  sexual  intercourse  when  in  a  state  of  drunk- 
enness. Inherited  insanity  does  not  therefore  come  here  into 
question, — for  the  parents  are  not  insane, — but  a  newly  arisen 
mental  disorder  supposed  to  be  due  to  an  acute  alcoholic  intoxi- 
cation. There  certainly  is  nothing  against  the  supposition  that 
the  alcohol  which  is  scattered  all  over  the  body  may  penetrate 
also  into  the  germ-cells,  even  if  they  have  been  already  dis- 
charged into  the  sexual  ducts,  and  produce  in  them  molecular 
changes  which  affect  particularly  those  parts  from  which  the 
cerebrum  of  an  eventual  foetus  evolves.  It  is  not  inconceivable 
that  this  disturbance  in  the  germ-cells  may,  like  other  phenomena 
of  an  acute  intoxication,  be  of  a  temporary  character  and  that 
permanent  injury  is  caused  to  the  descendant  only  if  copulation 
takes  place  before  the  effect  of  the  alcohol  has  disappeared, 
whereas  if  it  occurs  when  this  effect  has  passed  away  the  foetus 
suffers  no  consequences.  It  is  thus  perhaps  that  we  can  explain 
the  circumstance  pointed  out  byKraft-Ebingthat  the  evil  results 
of  sexual  intercourse  during  intoxication  may  occur,  but  that 
they  do  not  necessarily  occur  in  every  case.  It  would  still  how- 
ever remain  unexplained  how  it  is  that  the  disturbances  in  the 
embryonic  structure  are  not  equally  of  a  temporary  nature,  and 
why  they  become  permanent.  Some  may  even  doubt  whether 
the  parents  were  really  otherwise  perfectly  sane  and  be  inclined 
to  think  that  the  difference  in  the  results  ought  not  to  be 
attributed  so  much  to  the  extent  of  their  alcoholic  intoxication 
as  to  the  degree  of  their  sanity  which  was  not  perhaps  without 
its  blemishes.  In  any  case  it  is  not  possible  to  speak  of  inherited 


*Krafft-Ebing,  Grundziige  der  Kriminalpsychologie.    1872. 


58  HEALTH,  DISEASE,  MARRIAGE 

alcoholism,  as  it  is  only  degenerative  changes  which  come  into 
consideration  and  which,  even  if  they  are  hereditary,  are  only 
remote  consequences  of  the  effect  of  alcohol,  but  not  alcoholism 
as  such. 

Impregnation. — Another  remarkable  occurrence  which 
must  of  necessity  depend  upon  changes  in  the  maternal  germ- 
cells,  if  it  is  altogether  more  than  mere  chance,  is  designated 
by  the  name  of  impregnation.  It  is  especially  breeders  of 
thoroughbred  dogs  and  horses  who  think  that  they  have 
observed  that  male  animals  exert  an  influence  not  only  upon 
their  own  offspring  but  also  upon  the  offspring  resulting  from 
subsequent  copulation  with  any  other  male,  to  such  an  extent 
that  if  a  thoroughbred  female  is  once  covered  by  a  mongrel 
male  subsequent  copulation  with  thoroughbred  males  is  not 
productive  of  thoroughbred  offspring,  because  of  the  influence 
still  exercised  by  the  first  male.  To  my  knowledge,  similar 
observations  of  a  definite  character  have  not  been  made  with 
respect  to  man,  and  I  have  not  heard  for  instance  that  it  has 
ever  happened  that  the  children  of  a  woman  married  for  the 
second  time  have  borne  any  resemblance  to  her  first  husband; 
nevertheless,  the  following  very  extraordinary  case  has  been 
reported.1  A  man  affected  with  hypospadias  which  had  already 
shown  itself  in  three  generations  married  a  woman  of  a  healthy 
family  and  not  related  to  him,  who  bore  him  three  children  all 
of  whom  exhibited  the  malformation  and  transmitted  it  in  part 
eventually  to  their  descendants.  The  same  woman  though  not 
hereditarily  affected  married  subsequently  another  man  who  was 
also  healthy  and  not  hereditarily  affected  and  bore  him  four 
children  every  one  of  whom  exhibited  the  malformation  of  her 
first  husband.  The  offspring  of  two  of  these  children  were 
normal  but  some  of  that  of  the  other  two  presented  the  hypos- 
padiac  abnormality.  Now,  how  can  we  explain  such  an  heredity, 
if  we  may  call  it  so,  in  the  descendants  of  another  man?  There 
is  no  need  to  say  that  neither  imagination  on  the  part  of  the 
mother  nor  manifold  fecundation  will  here  serve  as  an  explana- 
tion; the  only  conceivable  possibility  is  that  spermatozoa  from 
the  first  husband  which  never  reached  any  ova  dissolved  them- 


lLingard,  Lancet.    1894,  I,  703. 


CONGENITAL  AND  INHERITED  DISEASES     59 

selves  in  the  woman's  body  and  became  so  to  speak  part  and 
parcel  of  it,  thus  producing  alterations  which  affected  also  the 
germ-cells  present  in  the  ovaries  and  bestowing  upon  them  the 
bodily  peculiarities  of  the  husband.  We  can  conceive  this  process 
either  as  a  direct  causation  brought  about  by  the  local  relations 
between  the  blighted  spermatozoa  and  the  ova  enclosed  in  the 
ovaries,  or  we  may  suppose  that  the  maternal  body  undergoes 
a  change  to  begin  with,  and  that  this  change  is  afterwards  in 
some  way  transferred  to  the  germ-cells  contained  in  the 
ovaries. 

Hereditary  transmission  of  acquired  pecu- 
liarities.— We  are  thus  approaching  the  great  and  important 
question  as  to  the  relations  existing  between  the  body  and  its 
single  parts  on  the  one  hand  and  also  between  it  and  the  germ- 
cells  contained  in  the  genital  glands  on  the  other,  a  question 
which  is  intimately  and  indissolubly  connected  with  that  of  the 
hereditary  transmission  of  acquired  peculiarities.  Can  an  indi- 
vidual, as  Virchow  thought,  transmit  hereditarily  all  that  he  has 
acquired,  without  any  exception,  or  are  there  any  limits  to  such 
a  transmission,  an  opinion  represented  principally  by  Weissmann 
and  opposed  to  Firchow's  teaching?  This  is  a  question  which 
has  been  very  much  discussed  during  the  last  thirty  years. 

According  to  what  has  been  said  above,  every  hereditary 
transmission  implies  a  participation  of  the  germ-cells;  new, 
acquired  peculiarities  can  only  be  so  transmitted  if  the  germ- 
plasma  has  undergone  a  corresponding  change.  An  alteration 
in  the  germ-plasma  is  therefore  a  necessary  preliminary  condi- 
tion of  hereditary  transmission  of  acquired  peculiarities.  Con- 
tinuity of  the  germ-plasma,  uninterrupted  transmission  of  the 
same  from  generation  to  generation  on  the  one  hand,  variability 
of  the  germ-plasma,  its  capability  to  experience  changes  on  the 
other — these  are  the  two  poles  round  which  the  theory  of 
heredity  turns.  Every  variation  in  the  germ-plasma  arising  in 
consequence  of  the  variability,  which  it  possesses,  and  which  is 
admitted  by  all  scientists,  can  be  transmitted  hereditarily  if  it 
is  not  counteracted  by  other  agencies.  It  is  obvious  that  newly 
arisen  variations  are  more  subject  to  such  counteractions,  than 
those  which  have  existed  for  some  time  and  become  more  firmly 


60  HEALTH,  DISEASE,  MARRIAGE 

established.  It  also  seems  that  those  variations  which  are 
rather  insignificant  persist  and  are  transmitted  more  easily  than 
marked  departures  from  the  normal  type.  But  whether  the 
change  is  great  or  small,  whether  it  persists  or  whether  it  dis- 
appears soon,  every  variation  in  the  germ-cells  is  something 
new,  something  that  did  not  exist  previously  in  the  germ-plasma 
of  the  ascendant,  the  bearer  of  the  inheritance,  therefore  some- 
thing foreign  to  the  latter,  something  contrary  to  it,  something 
acquired.  Inheritance  and  acquisition,  something  inherited  and 
something  acquired,  these  are  natural  antitheses,  and  what  does 
not  belong  to  the  one  must  be  attributed  to  the  other.  Every 
variation  in  the  germ-plasma  is  therefore  something  acquired, 
something  which  is  in  my  opinion  not  dependent  on  the  varia- 
bility originally  inherent  in  the  germ-plasma,  a  variability 
which  is  constantly  producing  changes  without  external  stimula- 
tion, a  sort  of  effect  without  its  proper  cause — but  something  as 
to  which  such  external  causes  form  the  determining  factor.  The 
whole  doctrine  of  a  phylogenetic  progressive  development  is 
based  upon  the  hereditary  transmission  of  acquired  qualities  on 
the  part  of  the  germ-plasma,  and  though  pathological  develop- 
ment is  not  a  progression  towards  a  higher  type,  but  signifies 
rather  a  degeneration,  its  main  process  cannot  possibly  be  any 
different  from  that  of  natural  development.  It  is  certainly 
strange  that  in  germ-variations  also  a  certain  regularity  is 
noticeable,  that  certain  typical  malformations  are  constantly 
recurring  in  the  same  manner  (polydactylism,  syndactylism, 
imperfect  union  in  the  extremities,  in  the  face  or  in  the  penis, 
naevi,  haemophilia,  colour  blindness,  myopia,  etc.)  ;  but  this  may 
perhaps  thus  be  explained,  viz.,  that  not  all  the  parts  of  the 
germ-plasma  are  equally  susceptible,  equally  variable,  and  that 
certain  external  causes  constantly  effect  in  the  same  way  certain 
divisions  of  the  germ-plasma  (so-called  determinants  of 
Weissmann}.  According  to  Wiedershein?  it  is  mostly  such 
parts  of  the  body  and  such  organs  as  are  engaged  in  a  con- 
tinuous phylogenetic  retrogression  or  transformation  that  are 
affected  by  the  variations. 


lWiedersheim,  Der  Bau  d.  Menschen,  u.  s.  w.  1887. 


CONGENITAL  AND  INHERITED  DISEASES     61 

Primary  and  secondary  germ-variation. —  It  is 

obvious  that  in  order  to  comprehend  fully  the  nature  of  these 
processes,  it  is  necessary  that  we  should  be  acquainted  with  the 
manner  in  which  the  external  agencies  that  produce  variations 
by  influencing  the  germ-plasma  act;  whether  they  have  an  imme- 
diate effect  upon  the  latter,  that  is  whether  they  produce  a 
direct  variation  in  it  (primary  germ-variation),  which  in  its 
turn  influences  the  germ-plasma,  or  whether  they  cause  in  the 
first  instance  a  change,  a  variation,  in  the  metazoic  bearer  of 
the  germ-plasma,  the  soma  (primary  soma-variation),  which 
in  its  turn  influences  the  germ-plasma,  thus  giving  rise  to  a 
secondary  germ-variation.  Between  them  stands  the  case  where 
the  external  agencies  produce  simultaneously  a  variation  in  the 
soma,  and  an  adequate  one  in  the  germ-plasma,  a  case  which 
can  be  separated  from  the  latter  alternative  only  with  some 
difficulty.  Both  in  the  second  and  middle  cases  it  is  possible 
where  correspondingly  altered  descendants  emanate  from  the 
germ-plasma,  to  speak  without  any  hesitation  of  hereditary 
transmission  of  acquired  peculiarities,  because  the  descendants 
exhibit  the  same  variation  as  their  immediate  ascendants.  In 
the  first  case,  however,  the  circumstances  are  different.  There 
the  soma  of  the  bearer  or  of  the  generator  of  the  germ-plasma 
shows  no  alteration,  and  such  alteration  only  appears  in  the 
body  of  the  descendant  emanating  from  the  germ-plasma  pri- 
marily altered.  In  a  former  work  *  on  the  origin  and  hereditary 
transmission  of  individual  characteristics  I  have  proposed  that 
this  kind  of  transmission  should  in  consideration  of  the  soma 
be  designated  as  hereditary  transmission  of  indirectly  acquired 
peculiarities  in  contradistinction  to  the  other  kind,  the  hereditary 
transmission  of  directly  acquired  peculiarities.  In  the  first  case 
the  transmission  has  not,  like  in  the  second,  been  effected  by  the 
soma  directly,  and  it  can  only  attain  a  somatic  appearance  if 
the  altered  germ-cell  impregnates,  or  is  impregnated  by,  another 
and  proceeds  towards  further  metazoic  development. 

Primary  germ=variation  through  amphimixis. 
— In  the   production   of  primary  pathologic   germ-variations 


*Orth,  Ueber  die  Entstehung  und  Vererbung  individueller  Eigenschaften. 
Festschrift  fur  A.  v.  Kolliker,  1887. 


62  HEALTH,  DISEASE,  MARRIAGE 

amphimixis  plays  a  very  considerable  part.  To  begin  with  the 
combination  of  the  two  germ-plasmas  is  alone  capable  of  giving 
rise  to  new  conditions,  as  is  amply  proved  by  the  cross-breeds 
of  both  human  and  animal  races.  How  different  the  cross- 
products  may  turn  out  both  physically  and  mentally  may  be 
seen  on  the  one  hand  in  the  offspring  resulting  from  the  union 
of  individuals  belonging  to  different  European  nations  with 
individuals  belonging  to  the  same  coloured  race  (English 
mulattoes  in  Jamaica  and  French  mulattoes  in  Guadeloupe  are 
totally  different  from  one  another  both  mentally  and  physi- 
cally) ,  and  on  the  other  in  the  different  cross-results  arising  from 
the  different  arrangements  in  the  sexes  of  the  same  races:  a 
white  man  with  a  coloured  woman  produces  quite  a  different  off- 
spring than  a  white  woman  with  a  coloured  man.  Experiments 
on  animals  also  show  that  the  wider  apart  the  germ-cells  are 
from  one  another  with  regard  to  their  origin  the  more  unsuitable 
they  are  for  the  purpose  of  procreating  a  healthy  and  vital 
cross-breed,  which  is  in  its  turn  capable  of  reproduction.  These 
cross-products  are  in  consequence  of  their  double  racial  origin 
pathologically  inclined  formations,  but  such  occur  also  among 
the  offspring  of  unmixed  unions,  as  the  result  of  the  copulation 
of  unsuitable  germ-cells,  as  suggested  especially  by  Ziegler. 

Marriage  among  blood-relations,  and  poten- 
tial heredity. — It  is  obvious  that  near  relationship  of  the 
germ-cells  does  not  as  a  matter  of  course  render  them  unsuit- 
able for  copulation.  In  and  in  breeding,  or  marriage  among 
blood-relations,  is  therefore  as  such  not  of  very  great  impor- 
tance as  a  cause  of  the  occurrence  of  pathologic  characteristics, 
and  there  are  numerous  cases  both  in  animals  and  human  beings 
where  copulation  by  very  near  relations  has  resulted  in  the  pro- 
creation of  absolutely  healthy,  well-formed  and  thoroughly 
reproductive  descendants.  If  among  the  offspring  of  incestuous 
intercourse  insanity  is  occasionally  observed,  this  is  not  due  so 
much  to  the  near  relationship  of  the  generative  cells  as  to  the 
probability  that  the  incestuous  parents  were  mentally  deficient 
and  that  the  incestuous  act  was  a  proof  of  this  deficiency.  In 
such  cases  it  is  not  difficult  to  suppose  that  the  insanity  as  such 
was  hereditarily  transmitted. 


CONGENITAL  AND  INHERITED  DISEASES     63 

There  is  no  doubt  that  the  danger  of  marriage  among 
blood-relations  consists  principally  in  the  circumstance  that  it 
occasions  an  accumulation  of  unfavourable  hereditary  predis- 
positions in  one  individual  (potential  heredity). 

Primary  germ-variation  in  the  free  germ-cells. 
— Interrupted  copulation  has  also  been  considered  as  a  cause 
of  the  production  of  new  pathologic  conditions.  Thus  it  has 
been  asserted  that  malformations  may  ensue  in  consequence  of 
the  entrance  of  more  than  one  spermatozoon  into  the  ovum; 
thus  the  possibility  has  recently  been  suggested  that  certain 
tumours  (teratomata,  embryomata)  may  result  from  the 
impregnation  of  a  polar  globule,  in  which  case  the  incomplete 
embryo  arising  from  this  secondary  impregnation  is  surrounded 
by  the  properly  fecundated  ovum.  The  circumstance  that  the 
male  as  well  as  the  female  germ-cells  may,  after  leaving  their 
places  of  origin,  remain  for  some  time  in  the  genital  ducts  of 
their  bearer  or  even  (the  spermatozoa  after  coitus)  in  the 
genital  ducts  of  the  other  individual,  and  that  they  must  travel 
a  certain  distance  before  reaching  copulation  (see  page  47), 
makes  it  possible  for  variations  to  arise  in  them  during  this 
interval  without  any  direct  interference  on  the  part  of  the 
parental  body.  New  peculiarities  may  thus  be  acquired  which 
only  become  manifest  in  a  corresponding  alteration  of  the  soma 
if  they,  the  germ-cells,  undergo  further  development.  The 
brothers  Hertwig  l  have  shown  that  the  eggs  of  sea-urchins 
which  in  the  fresh  state  are  able  to  repel  certain  foreign 
spermatozoa  lose  this  resisting  power  after  a  lengthy  sojourn 
in  sea-water  and  are  easily  impregnated  by  these  same 
spermatozoa.  This  proves  that  material  changes  may  take 
place  in  the  germ-cells  after  their  departure  from  their  places 
of  origin,  and  it  is  possible  that  in  man,  too,  such  changes  may 
occur  and  that  they  represent  variations  in  the  germ-plasma 
which  may  lead  to  an  alteration  in  the  soma  eventually  arising 
from  it.  As  I  have  already  explained,  I  do  not  think  it  likely 
that  such  germ-variations  may  be  produced  by  mental  impres- 
sions or  by  simple  imaginary  representations,  but  I  have  also 


*Hertwig,  O.  and  R.  Exper.  Unters.     iib.  d.  Bedingungen  der  Bastard- 
Befruchtung.    Jena  1885. 


64  HEALTH,  DISEASE,  MARRIAGE 

pointed  out  that  it  is  not  inconceivable  that  they  may  be  caused 
through  chemical  action.  If  the  above-mentioned  statements 
of  Krafft-Ebing  on  the  possible  results  of  intercourse  during  an 
attack  of  drunkenness  are  correct,  the  insanity  exhibited  by  the 
descendants  must  be  capable  of  hereditary  transmission,  seeing 
that  it  springs  from  the  germ-cells  and  that  it  is  based  upon  an 
alteration  in  the  germ-plasma.  If  it  is  merely  a  change  of  a 
degenerative  character  in  consequence  of  altered  nutrition  after 
the  discharge  from  the  germ  glands  and  of  other  external  con- 
ditions, disorders  may  arise  that  are  perhaps  the  starting  point 
of  many  a  miscarriage  for  which  a  plausible  explanation  is 
missing;  where  these  disorders  do  not  go  beyond  a  slight  extent 
they  produce  predispositions  to  disease  in  the  descendant  born 
alive,  which  as  they  are  due  to  an  alteration  in  the  germ-plasma 
are  also  capable  of  being  hereditarily  transmitted.  But  these  are 
all  purely  hypothetic  theories,  and  I  am  not  in  a  position  to 
adduce  any  proofs  of  the  existence  of  such  primary  germ- 
variations  and  of  indirectly  acquired  somatic  peculiarities  con- 
nected with  such  variations. 

Primary  germ-variations  in  the  germ=glands. — 
It  has  already  been  pointed  out  that  primary  germ-varia- 
tions may  arise  also  in  germ-cells  which  are  as  yet  contained  in 
the  germ-glands.  I  include  here  the  disturbance  in  the  develop- 
mental faculty — up  to  complete  sterility — of  the  generative 
cells  of  wild  animals  when  they  are  kept  in  captivity,  that  is 
under  external  conditions  totally  different  to  those  they  were 
previously  accustomed  to.  I  consider  that  the  similar  conditions 
occurring  in  the  human  female  as  so-called  climatic  disturbances 
(diminution  of  fecundity  up  to  complete  sterility  mostly  in  the 
third  generation)  also  belong  to  this  class,  though  the  abnormal 
external  conditions  apply  not  only  to  the  ova  but  also  to  the 
whole  rest  of  the  body,  and  there  is  a  possibility  that  what  takes 
place  is  not  a  primary  germ-variation,  but  a  secondary  one 
which  has  been  caused  by  a  previous  alteration  in  the  soma. 

Similar  doubts  arise  when  considering  the  question  of 
chronic  alcoholism  in  relation  to  mental  disorders.  Some 
psychiatrists  attach  considerable  importance  to  chronic  alco- 
holism as  a  cause  of  insanity  not  only  in  the  drinker  himself 


CONGENITAL  AND  INHERITED  DISEASES     65 

but  also  in  his  descendants,  and  we  may  well  ask  whether  the 
latter  have  inherited  an  acquired  abnormality.  Has  the  drunkard 
really  become  insane  as  a  consequence  of  alcoholism?  Or  was 
the  alcoholism  a  consequence  of  deranged  mental  activity?  In 
the  latter  case  it  would  not  be  very  difficult  to  regard  the 
insanity  of  the  descendants  as  a  result  of  heredity.  But  if  the 
premiss  is  wrong — and  there  are  drunkards  who  are  driven  to 
alcoholic  excess  not  by  an  inner  impulse,  but  by  external  cir- 
cumstances and  sometimes  even  against  their  will — the  query 
arises  whether  it  is  only  an  indirectly  acquired  condition  which 
appears  in  the  descendants,  as  a  result  of  a  primary  germ- 
variation  produced  by  the  alcohol,  such  as  occurs,  according  to 
Krafft-Ebing  after  intercourse  in  a  state  of  intoxication,  or 
whether  a  directly  acquired  peculiarity  has  been  hereditarily 
transmitted  in  consequence  of  a  secondary  germ-variation  in 
the  germ  glands  brought  about  by  the  alcoholically  diseased 
brain,  from  which  germ-variation  the  insanity  of  the  descend- 
ants ensued  as  a  necessary  result,  resting  therefore  on  a  heredi- 
tary basis. 

Secondary  germ-variation. — We  have  thus  come 
back  to  the  important  question  which  dominates  what  we  gen- 
erally speak  of  as  the  hereditary  transmission  of  acquired 
conditions,  that  is  the  hereditary  transmission  of  new  conditions 
which  the  soma  has  acquired,  namely  to  the  question  what  are 
the  relations  between  the  body  as  a  whole  and  its  constituent 
parts  on  the  one  hand,  and  the  germ-plasma  contained  in  the 
germ-glands  on  the  other.  If  a  decisive  influence  can  be  or  is 
exercised  on  the  part  of  the  single  constituents  of  the  soma  on 
the  germ-cells  enclosed  in  the  germ-glands  which  are  the  bearers 
of  heredity,  if  there  is  such  a  correlation  between  them  that 
acquired  changes  in  the  soma  are  capable  of  producing  adequate 
variations  in  the  germ-plasma  contained  in  the  germ-cells,  then 
it  is  possible  for  acquired  somatic  conditions  to  be  hereditarily 
transmitted,  otherwise  there  is  no  such  possibility. 

Relations  between  the  body  and  the  germ* 
cells. — It  is  obvious  that  the  germ-cells  are  dependent  upon 
the  body  for  their  nutrition.  The  uninterrupted  transference  of 
the  germ-plasma  to  an  unlimited  number  of  descendants,  the 


66  HEALTH,  DISEASE,  MARRIAGE 

phylogenetic  eternity  of  the  germ-plasma  is  necessarily  supposed 
to  be  based  upon  its  multiplication  in  every  single  individual, 
which  multiplication  in  its  turn  can  only  go  on  by  means  of  a 
continuous  nutrition.  The  question  arises  whether  the  body 
though  it  is  itself  dependent  upon  an  extraneous  food  supply  is 
capable  of  exercising  an  alterative  influence  on  the  germ-cells 
by  providing  them  with  a  special  kind  of  nutrient  material.  I 
should  imagine  that  there  are  sufficient  reasons  for  assuming 
that  it  is  possible  by  a  permanent  qualitative  change  of  food  to 
bring  about  an  alteration  in  the  somatic  quality  though  there 
must  be  other  factors  concerned  as  well  and  it  is  quite  con- 
ceivable that  by  a  corresponding  change  in  the  germ-plasma  a 
sort  of  accommodation  to  the  altered  nutrition  takes  place, 
thereby  creating  an  hereditary  somatic  variation.  Of  course  we 
must  not  forget  in  this  connection  that  a  similar  mode  of  nutri- 
tion on  the  part  of  the  descendants  themselves  may  have  pre- 
cisely the  same  results. 

Is  it  also  due,  I  wonder,  to  conditions  of  nutrition  that 
the  children  of  older  individuals  whose  fecundity  is  about  to 
expire  so  frequently  present  a  feeble  constitution,  and  that  they 
so  often  perish  from  want  of  vitality  ?  Who  can  say  that  what 
we  see  in  these  cases  is  only  a  result  of  a  regularly  recurring 
evolution  of  the  germ-plasma  or  that  there  do  not  exist  also 
other  relations? 

Undoubtedly  there  are  such  relations  between  the  germ- 
cells  and  the  rest  of  the  body.  They  are  in  the  first  instance  of 
a  nervous,  in  the  second  of  a  chemical  nature.  Both  emanate, 
to  begin  with,  from  the  germ-glands;  these  produce  by  reflex 
action  nervous  processes  which  are  capable  by  internal  secretion 
of  influencing  chemically  most  distant  parts  of  the  body.  But 
does  the  body  as  a  whole,  do  single  constituents  and  organs  of 
it  also  exercise  a  nervous  influence  upon  the  germ-cells?  Can 
the  germ-plasma  present  in  the  germ-cells  be  definitely  influ- 
enced by  chemical  substances  which  spring  directly  from  the 
various  parts  of  the  body,  or  are  formed  secondarily  through 
nervous  processes?  Who  can  declare  this  to  be  impossible? 
And  who  can  prove  it?  The  third  possible  explanation,  namely 
that  in  addition  to  nervous  and  chemical  agencies  there  are 


CONGENITAL  AND  INHERITED  DISEASES     67 

minute  physical  elements  (whether  we  call  them  as  Darwin  did 
"gemmules"  or  by  any  other  name)  which  are  constantly  car- 
ried by  the  blood  from  the  smallest  parts  of  the  body  to  the 
germ-cells  and  are  capable  of  causing  such  variations  in  the 
germ-plasma  as  will  afterwards  invest  the  soma  springing  from 
it  with  peculiar  characteristics,  this  explanation  is  absolutely 
groundless  and  probably  at  the  present  time  accepted  by  hardly 
anybody. 

There  are  consequently  many  things  imaginable  with 
regard  to  the  decisive  relations  between  single  parts  of  the 
body  and  the  germ-plasma  enclosed  in  the  germ-glands;  a  cer- 
tain scientific  interpretation  by  what  means  variations  in  the 
germ-plasma  may  produce  in  this  or  that  part  of  the  descend- 
ants' soma  similar  alterations,  so  that  they  may  be  regarded 
as  inherited,  is  not  impossible;  the  possibility  of  an  hereditary 
transmission  of  certain  acquired  peculiarities  of  the  soma  cannot 
therefore  in  principle  be  altogether  excluded,  but  then  this  is 
in  my  opinion  all  that  can  be  said.  For  the  rest,  the  theory 
leaves  us  entirely  in  the  dark  and  it  cannot  tell  us  anything 
conclusive.  Thus  there  remains  in  answer  to  the  question 
whether  there  exists  an  hereditary  transmission  of  acquired  con- 
ditions nothing  but  experience,  and  we  must  for  the  present 
devote  our  energy  towards  the  elucidation  of  the  facts  which 
tend  to  show  that  such  a  transmission  does  exist  and  particu- 
larly of  those  facts  which  do  not  admit  of  any  other  explanation. 
Hereditary  transmission  of  mutilations.  — 
It  may  be  presumed,  to  begin  with,  that  the  relative  impor- 
tance of  the  various  parts  of  the  body  to  the  germ-plasma, 
— once  we  admit  the  hypothesis  that  the  possible  relations  above 
described  exist  in  reality, — that  the  degree  of  connection  between 
parts  of  the  body  and  the  germ-cells,  must  vary  according  to 
the  altruistic  significance  of  the  parts  of  the  body.  It  is  there- 
fore necessary  in  discussing  the  question  of  hereditary  transmis- 
sion of  acquired  conditions  to  consider  special  possibilities. 
The  question  whether  mutilations  of  non-vital  parts,  especially 
of  the  extremities  or  of  the  surface  of  the  body  in  general, 
are  hereditary  or  not,  has  recently  been  answered  by  almost 
all  authors  in  the  negative;  and  rightly  so,  considering  that  no 


68  HEALTH,  DISEASE,  MARRIAGE 

conclusive  proofs  have  been  furnished  to  demonstrate  the  exist- 
ence of  such  an  heredity,  whereas  on  the  other  hand  numerous 
weighty  observations  have  been  made  in  human  beings  which 
speak  against  it. 

There  is  a  natural  mutilation  which  has  for  thousands  of 
years  recurred  again  and  again,  and  which  will  continue  to 
recur,  because  it  has  not  become  superfluous  through  hereditary 
transmission — that  is  the  rupture  of  the  hymen.  There  is  even 
no  reason  for  assuming  that  this  little  membrane  is  of  any  use — 
on  the  contrary,  it  were  better  if  it  did  not  exist — yet  it  is  con- 
stantly forthcoming  and  it  must  constantly  be  ruptured  at  the 
first  sexual  intercourse.  If  we  want  an  example  of  a  mutilation 
which  is  not  required  by  nature,  we  have  one  in  the  circum- 
cision of  numerous  generations  of  various  nations  in  whom  the 
prepuce  is  nevertheless  as  a  rule  present  again  and  again, 
though  they  are  the  descendants  of  circumcised  ancestors.  We 
have  other  examples  in  the  crippled  feet  of  Chinese  women, 
in  the  artificial  deformities  of  the  skull,  which  have  to  be  pro- 
duced anew  in  every  fresh  generation.  These  examples  are  the 
more  important  as  they  refer  to  young  individuals,  and  because 
it  is  said  that  the  tendency  to  transmit  hereditarily  acquired 
conditions  is  especially  great  in  young  people  and  that  it  gradu- 
ally diminishes  as  age  advances. 

Does  this  apply  also  to  the  mutilation  of  internal  vital 
organs?  Only  very  little  is  known  on  this  point.  Massoin  1  has 
reported  a  case  of  artificially  produced  atrophy  of  the  spleen 
which  was  hereditarily  transmitted,  but  it  is  principally  the 
experiments  of  Brown-Sequard  and  of  his  successors  on  the 
hereditary  transmission  of  artificially  produced  epilepsy  which 
are  frequently  quoted  as  evidence.  By  certain  operative  injuries 
to  the  nervous  system  (injury  to  the  sciatic  nerve,  or  uni-lateral 
section  of  the  spinal  cord)  Brown-Sequard  has  succeeded  in 
making  rabbits  epileptic  and  in  observing  the  same  conditions 
in  their  non-operated  offspring;  in  connection  with  these  experi- 
ments it  was  noticed  that  the  operated  females  were  more 
suitable  for  hereditary  transmission  than  the  males.  Westphal 


'Bulletin  de  1'acad,  roy.  de  med.  de  Belgique.    XIV,  772,  1880. 


CONGENITAL  AND  INHERITED  DISEASES     69 

has  obtained  similar  results  by  injuries  to  the  brain,  and  even 
by  blows  on  the  head;  other  experimenters,  however,  have  not 
been  so  successful  as  they  either  did  not  notice  any  alterations 
at  all  in  the  offspring1  or  they  did  not  see  epilepsy  exclusively. 
Thus  Obersteiner  saw  among  32  young  rabbits  descended  from 
artificially  epileptic  parents  only  2  epileptics  and,  in  17,  weak- 
ness, paresis,  neuro-paralytic  eye-affections,  in  short,  all  sorts 
of  nervous  disorders,  therefore  a  well-marked  polymorphous 
heredity,  that  is  a  heredity  transmission  not  of  a  disease,  but 
of  a  nervous  degeneration,  of  a  predisposition.  The  last  word 
has  not  yet  been  spoken  on  this  subject,  but  I  think  it  must  be 
recognised  that  these  experiments  have  at  least  demonstrated 
the  possibility  of  a  hereditary  transmission  of  acquired  injuries 
of  the  n'ervous  system.  It  is  only  possible  to  explain  this  by 
supposing  that  the  brain  has  permanently  influenced  the  germ- 
cells.  As  to  why  females  should  have  appeared  to  be  more  com- 
petent for  the  transmission  than  the  males,  this  might  possibly 
be  accounted  for  by  the  circumstance  that  the  development  of 
the  male  germ-cells  proceeds  at  a  quicker  and  more  active  rate 
than  that  of  the  female  germ-cells  and  that  the  male  germ- 
plasma  multiplies  therefore  more  quickly  and  more  numerously 
than  the  female.  The  latter  may  consequently  perhaps  be  sub- 
ject to  greater  influence,  seeing  that  the  influencing  agencies 
are  equally  great  in  both  sexes  and  that  there  are  not  as  many 
female  as  male  carriers  of  germ-plasma  to  divide  the  effect  of 
those  agencies. 

The  hereditary  transmission  of  functional 
acquisitions. —  If  the  possibility  of  a  hereditary  transmis- 
sion of  traumatically  acquired  new  qualities  cannot  be  excluded, 
there  is  even  more  reason  to  admit  theoretically  that  such  a 
transmission  exists  with  respect  to  changes  in  different  parts 
brought  about  by  use  or  non-use.  It  is  perhaps  necessary  to 
distinguish  here  also  between  important  and  unimportant  parts, 
between  extremities,  outer  coverings  and  internal  organs, 
although  it  has  been  maintained,  for  instance,  that  the  knee- 
calosities  present  in  camels  employed  as  beasts  of  burden  are 
hereditary  while  they  are  entirely  absent  in  the  animals  living 

1Sommer,  Ziegler's  Beitr.  27  Bd.  1900. 


70  HEALTH,  DISEASE,  MARRIAGE 

in  a  wild  state.  The  productiveness  of  the  udder  in  cows  has 
been  considerably  increased  by  artificial  training;  on  the  other 
hand  there  are  gynaecologists  who  incline  to  the  opinion  that 
the  breasts  in  women  have  undergone  considerable  hereditary 
degeneration  on  account  of  the  growing  practice  not  to  demand 
any  service  from  them. 

Breeders  of  animals  believe  also  that  intellectual  faculties 
acquired  by  practice  are  hereditarily  transmissible.  As  regards 
man  experience  has  shown  that  most  highly  gifted  and  talented 
individuals  may  spring  from  circles  with  very  limited  mental 
activity,  and  vice-versa,  that  very  often  the  nearest  descendants 
of  most  clever  men  whose  minds  were  constantly  employed 
hardly  reach  mediocrity.  But  these  are  perhaps  exceptions,  and 
we  may  take  it  that  as  a  rule  non-use  of  a  faculty  leads  to 
its  hereditary  diminution  and  use  to  its  hereditary  increase. 

Hereditary  transmission  of  chemical  changes. 
— Above  all  we  are  justified  in  thinking  of  a  hereditary  trans- 
mission of  acquired  conditions  when  chemical  changes  come 
into  consideration,  due  perhaps  to  the  absence  of,  or  an  altera- 
tion in,  a  so-called  internal  secretion.  It  was  hoped  that  the 
knowledge  recently  gained  with  regard  to  immunisation  would 
also  lead  to  an  advancement  of  the  doctrine  of  heredity  and 
some  observers  have  already  spoken  of  a  hereditary  transmis- 
sion of  an  artificially  produced  immunity.  There  can  be  no  doubt 
about  this,  since  experiments  as  well  as  observations  in  man 
have  proved  beyond  doubt  that  there  exists  a  congenital  intra- 
uterine  immunity,  but  we  know  that  this  is  not  evidence  of  the 
hereditary  transmission  of  acquired  conditions,  and  that  it  might 
be  nothing  more  than  a  purely  placental  transference  of  the 
immunising  substances.  Proofs  of  a  hereditary  transmission 
of  the  immunity  could  only  be  forthcoming  if  it  were  possible 
to  show  that  an  acquired  immunity  can  be  transmitted  to  the 
offspring  through  the  semen.  Unfortunately  this  does  not 
appear  to  be  the  case,  certainly  not  as  regards  abrin  and  ricin 
immunity  so  that  congenital  immunity  where  it  does  occur  does 
not  rest  upon  heredity  but,  if  one  may  say  so,  upon  a  placental 
intoxication. 

But  even  if  it  were  possible  to  prove  that  a  transmission 


CONGENITAL  AND  INHERITED  DISEASES     71 

of  an  acquired  immunity  does  take  place  occasionally  from 
parents  to  offspring  through  the  germ-cells;  if  it  should  turn 
out  to  be  correct  that  a  natural  immunity,  as  f.  i.  that  of  ancient 
civilised  nations  towards  some  infectious  diseases,  is  due  to  an 
acquired  immunity  being  transmitted  hereditarily,  it  would  still 
be  necessary,  in  order  to  look  upon  it  as  an  example  of  heredi- 
tary transmission  of  directly  acquired  qualities,  to  demonstrate 
that  it  is  not  a  primary  variation  of  the  germ-plasma,  but  a 
secondary  and  subordinate  one  equal  in  its  effect  to  the  varia- 
tion in  the  soma.  In  the  latter  case  it  would  only  be  an  indirect 
germinative  acquisition  which  must  be  judged  quite  differently. 

The  same  doubt  arises  in  all  those  cases  in  which  a  physical 
anomaly  suddenly  appears  in  a  family  or  in  which  predis- 
positions to  disease  of  any  kind  show  themselves.  Be  it 
hexadactylism,  or  hypospadias,  or  haemophilia,  or  gout,  dia- 
betes or  anything  else,  proof  will  hardly  be  forthcoming  that 
a  primary  variation  in  the  germ-plasma  is  not  accountable  for 
the  first  case,  and  if  it  is  so,  there  is  nothing  extraordinary  in 
the  variation  being  hereditary — but  it  is  not  in  such  a  case  a 
hereditary  transmission  of  acquired  conditions  in  the  sense  in 
which  the  term  is  generally  taken. 

SUMMARY. — In  summing  up  the  theoretical  foundations 
of  heredity  they  may  be  recapitulated  in  brief  as  follows: 
Qualities  which  are  derived  from  the  continuity  of  the  germ- 
plasma  are  inherited  and  hereditarily  transmissible  qualities; 
what  has  arisen  through  primary  variation  of  the  germ-plasma 
and  appeared  for  the  first  time  in  the  offspring  is  acquired  indi- 
rectly and  can  also  be  hereditarily  transmitted;  that  which  pro- 
duces a  secondary  but  adequate  variation  in  the  germ-plasma 
after  having  appeared  first  in  the  soma  of  the  same  generation 
is  acquired  and  hereditarily  transmissible,  but  acquired  condi- 
tions of  the  soma  which  do  not  produce  an  adequate  variation 
in  the  germ-plasma  cannot  possibly  be  so  transmitted.  This 
seems  to  apply  to  all  mutilations  of  external  and  superficial 
parts. 

Potency  of  heredity. — If  we  compare  to  one  another 
the  different  cases  which  exhibit  a  hereditary  transmission  of 
particular  qualities,  a  series  of  special  phenomena  appear  both 


72  HEALTH,  DISEASE,  MARRIAGE 

in  normal  and  abnormal  heredity,  which,  though  it  may  not  be 
justifiable  or  advisable  to  designate  as  laws,  manifest  very  often 
a  certain  regularity  and  are  therefore  worthy  of  a  brief  con- 
sideration. 

Although  theoretically  speaking  the  hereditary  tendency  of 
the  male  and  female  germ-cells  is  exactly  the  same,  it  is  well 
known  that  heredity  as  a  whole  as  well  as  with  regard  to  single 
parts  of  the  body  is  very  variable  not  only  in  respect  of  the  two 
sexes  but  also  in  respect  of  different  parts  of  the  body  in  the 
same  sex.  As  regards  both  normal  and  pathologic  physical 
peculiarities,  it  is  sometimes  the  paternal  influence  which  pre- 
dominates and  sometimes  the  maternal,  so  that  the  children 
are  constitutionally  sometimes  more  like  the  father,  and  at  other 
times  more  like  the  mother.  In  some  cases  the  paternal  heredity 
seems  to  predominate  at  one  period  of  the  child's  life  and  the 
maternal  at  another,  and  frequently  such  a  mingling  of  the 
two  takes  place  that  a  similarity  f.  i.  in  the  facial  features  in 
either  direction  is  altogether  absent,  and  something  totally  new 
and  different  makes  its  appearance.  That  certain  parts  of  the 
body  may  reveal  a  striking  hereditary  character  is  evidenced 
by  the  noses  of  the  Bourbons  and  the  lips  of  the  Hapsburgs 
whose  male  scions  have  transmitted  their  facial  peculiarities  to 
their  descendants  though  married  to  women  of  most  varied 
descent.  Pathological  conditions  equally  show  very  different 
tenacity;  some  can  be  made  to  disappear  only  very  slowly, 
others,  f.  i.  certain  mental  degenerative  symptoms,  can  be 
counteracted  more  quickly  and  successfully  by  the  introduction 
of  non-predisposed  germ-cells. 

Crossed  heredity. — The  descendants  of  opposite  sex 
may  resemble  each  other  completely  or  they  may  be  totally 
unlike  changing  according  to  sex  or  even  in  the  same  sex ;  some- 
times there  is  a  crossed  heredity,  that  is,  the  sons  resemble 
more  the  mother  and  the  daughters  more  the  father.  There  is 
no  fixed  law  whatever  in  the  matter  although  there  may  be 
certain  general  differences  as  regards  the  quality  of  the  heredity 
on  the  part  of  the  male  and  female  ancestors  respectively  as 
suggested  especially  by  Orschansky.1  This  observer  says  that 


lOrschansky,  1.  p.  c.,  page  345. 


CONGENITAL  AND  INHERITED  DISEASES     73 

each  of  the  two  procreators  plays  in  heredity  a  special  definite 
part;  the  variability  or  individuality  is  influenced  by  the  paternal 
element,  whereas  the  maternal  tends  to  maintain  the  average 
type.  The  mother  transmits  a  minimum  of  pathologic  heredity, 
she  offers  energetic  resistance  to  the  disease-producing  influence 
of  the  father  and  finally  transforms  a  severe  hereditary  pre- 
disposition into  one  of  a  less  threatening  type. 

Homosexual  heredity. — That  the  sex  as  such  is  not 
without  significance  in  the  hereditary  transmission  of  predis- 
positions to  disease,  that  the  general  sexual  tendency  has  some 
definite  and  influencing  bearing  on  the  pathologic  proclivity, 
in  other  words,  that  heredity  does  not  depend  only  on  the 
parents  but  also  on  the  offspring  themselves,  and  especially 
on  their  sex,  this  is  clearly  seen  in  the  homosexual  character 
which  is  distinctly  apparent  in  some  pathological  hereditary  con- 
ditions. Thus  there  have  been  haemophilic  families  in  which 
only  the  male  members  but  none  of  the  female  showed  the 
hereditary  affection.  Nevertheless  the  important  observation 
has  been  made,  in  haemophilia  and  in  other  anomalies  as  well, 
that  although  the  women  did  not  present  any  traces  of  the 
inherited  peculiarity  in  themselves,  they  were  yet  capable  of 
transmitting  the  same  to  their  male  descendants. 

Latent  heredity. — That  is  a  case  of  so-called  latent 
heredity  which  proves,  particularly  as  regards  haemophilia,  that 
it  is  not  the  disease  which  is  inherited,  but  a  predisposition  to 
it,  from  which  the  disease  itself  need  not  necessarily  result.  For 
it  is  evident  that  the  women  must  have  possessed  the  predis- 
position in  question  considering  that  they  were  able  to  transmit 
it  and  that  certain  special  circumstances  obviously  connected 
with  the  female  sex,  prevented  it  from  developing  into  disease. 

Collateral  heredity. — Latent  heredity  plays  a  part  also 
in  the  so-called  collateral  heredity,  in  which  normal  or  patho- 
logical conditions  were  present  not  in  the  direct  ascendants  but 
in  collateral  ones,  that  is,  uncles,  aunts,  etc.  Of  course  these 
collateral  ascendants  could  not  possibly  transmit  anything,  and 
for  this  reason  the  term  collateral  heredity  does  not  seem  very 
appropriate.  The  explanation  is  probably  that  a  common 
ancestor  was  the  transmitter  of  the  peculiarity  in  question,  and 


74  HEALTH,  DISEASE,  MARRIAGE 

that  among  the  offspring  affected  with  the  latter  one  or  two  did 
not  exhibit  it  manifestly;  that  the  parent  male  or  female  of  a 
particular  descendant  was  one  of  those  who  inherited  the  pecu- 
liarity latently,  and  that  he  or  she  was  able  to  transmit  it  to  his 
or  her  offspring  directly,  or  even  through  one  or  two  genera- 
tions also  latently  in  whom  it  reappeared  in  full  strength.  But 
even  in  latent  heredity  it  is  not  absolutely  necessary  that  there 
should  be  a  hereditary  transmission  of  a  particular  peculiarity, 
as  the  case  might  be  nothing  but  the  result  of  external  circum- 
stances. Thus  Delage  *  has  expressed  the  opinion  that  there  is 
no  latent  heredity  as  regards  special  parts  of  the  body,  but  that 
the  ovum  has  a  definite  physico-chemical  composition  which  per- 
mits it  under  favourable  circumstances  to  develop  within  certain 
physiological  limits;  it  would  then  depend  entirely  on  external 
circumstances  whether  that  development  inclines  to  the  one 
limit  or  the  other;  with  regard  to  the  nose,  f.  i.,  it  might  be 
the  same  limit  in  the  grandfather  and  the  grandson  and  the 
other  limit  in  the  case  of  the  father.  It  would  therefore  not 
be  correct  to  speak  of  a  latent  hereditary  transmission  of  the 
grandfather's  nose  to  the  grandson,  as  the  same  external  circum- 
stances may  have  produced  the  same  result.  Such  an  explanation 
however  is  not  admissible  in  the  case  of  pathologic  conditions 
which  have  been  latently  inherited  just  because  they  are  not 
phenomena  coming  within  physiological  limits  but  are  altogether 
outside  the  range  of  physiological  normality. 

Reaction,  Atavism. — In  these  cases  of  latent  hereditary 
transmission  there  is  a  so-called  return  to  ancestral  conditions; 
if  the  ancestors  in  question  were  a  few  generations  removed  we 
speak  of  atavism.  But  as  it  is  not  only  a  return  to  more  or  less 
remote  ancestral  conditions  which  is  assumed  but  also,  especially 
as  an  explanation  of  animal-like  formations  (theromorphism), 
to  species  which  are  very  far  removed  in  the  phylogenetic 
genealogical  tree,  it  is  necessary  to  distinguish  clearly  between 
family  atavism  and  phylogenetic  atavism.  It  is  the  latter  which 
has  been  advanced  as  an  explanation  of  all  kinds  of  pathological 
conditions  (polydactylism,  polymastia,  microcephalism,  etc.)  of 
which  it  has  been  said  that  they  have  arisen  through  latent 

M.  p.  c. 


CONGENITAL  AND  INHERITED  DISEASES     75 

heredity.  As  to  some  of  the  conditions  pertaining  to  this  class 
however,  their  purely  pathological  character  has  been  demon- 
strated; with  regard  to  others  it  is  sufficient  to  say  that  they 
are  due  to  an  arrested  development,  since  even  animal-like 
formations  (theromorphism)  may  easily  be  caused  by  it,  and 
since  ontogeny  is  to  a  certain  extent  a  recapitulation  of  phylo- 
geny.  It  might  therefore  be  permissible  to  speak  of  an  onto- 
genetic  atavism.  Nevertheless  some  biologists  have  even  in 
recent  days  spoken  approvingly  of  phylogenetic  atavism  and 
phylogenetic  latent  heredity.  Special  stress  has  been  laid  on  the 
atavistic  character  of  certain  so-called  degenerative  phenomena 
in  hereditary  insanity  in  which  a  secondary  origin  has  been 
thought  of  as  a  consequence  of  the  cessation  of  the  altruistic 
activity.  The  primary  disorder  need  not  therefore  be  also  an 
atavistic  one;  Lombroso's  idea  of  the  "homo  delinquens"  as  a 
sign  of  return  to  our  wild  ancestors  has  found  no  supporters. 
Corresponding  heredity. — It  has  already  been  men- 
tioned that  inherited  predispositions  may  not  mature  fully  before 
the  period  of  extra-uterine  development,  so  that  they  are  not 
complete  at  birth  and  only  show  themselves  at  a  later  period 
of  life.  This  condition  has  been  called  corresponding  heredity, 
if  the  predisposition  appears  in  several  generations  at  the  same 
time  of  life. 

Homoeo=hetero=polymorphous  heredity. —  He- 
redity may  be  homomorphous  or  heteromorphous ;  in  the 
former  kind  an  equal  condition  appears  in  the  offspring  (hexa- 
dactylism,  hypospadias,  tendency  to  haemophilia,  gout,  etc.)  or 
something  else,  perhaps  something  in  many  ways  different.  In 
such  case  we  speak  of  a  polymorphous  heredity,  an  example 
of  which  we  often  see  plainly  in  mental  diseases  of  a  hereditary 
nature.  Nevertheless  the  conditions  are  all  of  the  same  class, 
though  quite  different  disturbances  affecting  different  parts  of 
the  body  have  been  associated  and  a  far-reaching  transformism 
has  been  assumed.  Thus  Orschansky  1  quotes  as  an  example  of 
transformation  of  inherited  forms  of  disease  the  observation 
that  the  children  of  fathers  suffering  from  diseases  of  the  chest 
are  frequently  subject  to  nervous  or  mental  diseases.  He  says: 

*l.  P.  c.,  p.  270. 


76  HEALTH,  DISEASE,  MARRIAGE 

"For  this  reason,  the  transformation  of  that  form  of  disease 
from  which  the  parents  suffered  appears  in  a  new  pathological 
variation  as  a  main  peculiarity,  almost  as  a  law  for  the  whole 
range  of  pathological  heredity.  Functional  diseases  of  the 
mother  are  frequently  transformed  into  a  more  constant  and 
more  severe  organic  disease  in  the  son,  and  an  organic  disease 
of  the  father  is  no  less  often  transformed  into  less  serious  func- 
tional disorders  in  the  daughter."  It  is  always  a  risky  thing  to 
lay  down  laws  with  regard  to  normal  or  pathological  heredity, 
and  many  a  law  thus  laid  down  has  been  afterwards  demolished 
by  the  facts,  but  the  transformistic  theory  is  not  without  its 
supporting  realities.  Heredity  need  not  confine  itself  to  special 
parts  of  the  body.  It  may  cause  a  deficiency  in  the  constitution 
as  a  whole.  It  is  possible  for  a  general  dystrophy  or  degenera- 
tion to  be  present  and  to  be  inherited.  What  will  emerge  from 
that  general  unfavourable  predisposition,  where  disease  will 
make  its  appearance,  of  what  form  that  disease  will  be,  all  this 
depends,  like  in  the  polymorphous  heredity  of  insanity, 
entirely  upon  external  circumstances.  For  here  also  not  a  dis- 
ease has  been  inherited,  but  only  a  general  inclination  to 

disease.  

The  literature  on  the  points  discussed  in  this  article  is 
enormous  and  it  is  impossible  to  give  complete  references  here. 
I  mention  therefore  only  a  few  recent  works  in  which  the 
literature  on  the  subject  will  also  be  found. 

Literature. 

E.  Roth,  Die  Tatsachen  der  Vererbung,  2.  Aufl.   Berlin  1885. 

F.  Rohde,  Ueb.  d.  gegenwartigen  Stand  der  Frage  nach  der  Enstehung 
und  Vererbung  individueller   Eigenschaften  und  Krankheiten.    Jena  1894. 

P.  Le  Gendre,  L'heredite  et  la  pathologic  gener.  in  Traite  de  Pathol. 
gener.,  public  par  Ch.  Bouchard,  T.  I.  Paris  1895. 

Lubarsch,  Ergebn.  d.  allg.  Path.  I,  S.  427. 

A.  Dietrich,  Die  Bedeutung  der  Vererbung  fur  d.  Pathologic.  Tubingen 
1902.  (Mit  Literaturzusammenstellung.) 

Wassermann,  Erbl.  Uebertragung  d.  Infektionskrankheiten.  Hbd.  d. 
pathogen.  Mikroorg.  I,  380,  1902. 

Yves  Delagc,  L'heredite  et  les  grands  problemes  de  la  biologic  generate, 
2.  Ed.  Paris  1903.  (Mit  eingehender  Literaturberiicksichtigung.) 

Orschansky,  Die  Vererbung  im  gesunden  und  krankhaften  Zustande. 
Stuttgart  1903. 

Schwalbe,  D.  Problem  d.  Vererbung  in  d.  Pathologic.  Munch,  med. 
Woch.  1903. 


IV 


Consanguinity  in    Marriage  and  its   Effects 
on   the    Offspring 


IV. 

CONSANGUINITY    IN    MARRIAGE  AND  ITS 
EFFECTS  ON  THE  OFFSPRING. 

By  Professor  F.  Kraus  (Berlin). 

Introduction. — The  question  as  to  the  injuriousness  of 
marriage  between  blood-relations  has  already  produced  a  very 
extensive  literature.  By  far  the  greater  number  of  authors 
incline  to  the  opinion  that  such  marriages  are  harmful  and  seek 
to  prove  its  correctness  by  the  frequent  occurrence  of  predis- 
positions to  disease  and  of  disease  proper  among  the  descendants 
of  blood-relations.  Others  again  attempt  to  establish  as  prob- 
able exactly  the  opposite  of  this,  or  they  make  so  many  reserva- 
tions that  the  absence  of  outside  blood  as  the  exclusive  cause 
of  organic  degeneration  in  the  offspring  is  divested  of  all  special 
significance.  Nothing  would  be  easier  than  to  quote  here  a 
large  number  of  contrasting  views,  and  the  most  careful  observ- 
ers agree  in  declaring  the  question  as  by  no  means  finally 
solved. 

The  great  divergence  in  our  present  scientific  views  of  the 
injuriousness  of  consanguinity  in  marriage  depends  probably  on 
various  causes.  In  the  first  instance  the  question  is  a  difficult  and 
complicated  one.  It  has  never  been  impartially  examined  into 
whether  marriage  between  blood-relations  does  not  present  also 
at  least  certain  one-sided  advantages  to  the  offspring,  relating 
for  example  to  mental  development,  such  as  we  have  reason  to 
expect  in  accordance  with  the  laws  of  heredity.  Generally 
speaking  neither  question  nor  proofs  have  been  advanced  with 
sufficient  regard  to  the  facts  and  laws  of  heredity  though  not 
even  in  this  way  do  we  always  arrive  at  the  same  result. 


8o  HEALTH,  DISEASE,  MARRIAGE 

Influence  of  heredity. — Consanguinity  is  first  of  all 
capable  of  producing  an  easily  imaginable  augmentation  in  the 
effect  of  heredity.  (Summation  of  the  predispositions  by  poten- 
tial, combined  heredity.)  And  it  is  further  conceivable  at  least, 
that  it  may  form  per  se,  even  without  any  manifest  hereditary 
predisposition  and  in  the  case  of  apparently  perfect  procreators 
the  cause  of  certain  diseases.  But  in  such  a  case,  even  if  we  do 
not  exactly  adhere  to  Weissmanris  strict  theory  of  heredity  and 
agree  with  the  less  rigorous  view  of  Orth,  new  qualities,  of 
whichever  kind  they  may  be,  can  only  be  inherited  through  a 
series  of  generations  if  influences  are  really  exercised  through 
the  consanguinity  upon  the  germ-plasma  directly  or  in  conjunc- 
tion with  the  whole  soma,  thus  producing  degenerate  germ- 
variations  which  are  hereditarily  transmitted  through  subsequent 
generations.  There  are  however  at  the  most  only  very  few 
such  external  influences  upon  the  germ-plasma  known  to  path- 
ology (suitable  examples  might  be  found  perhaps  in  the  pre- 
dispositions to  disease,  and  in  the  injury  to  the  germ-cells 
caused  by  alcohol).  But  where  no  degeneration  of  the  germ 
takes  place  there  is  no  hereditary  transmission  to  subsequent 
generations,  and  nothing  of  consequence  occurs.  By  observing 
strictly  the  laws  of  heredity  one  is  never  certain  when  examin- 
ing statistically  into  one  and  the  same  peculiarity  (good  or 
bad)  of  a  number  of  people  descending  from  a  consanguineous 
marriage  that  predisposition  through  heredity  in  the  narrower 
sense  can  be  excluded  entirely.  Because  from  the  laws  of 
heredity  the  possibility  arises  that  two  similar  predispositions 
which  are  not  on  account  of  their  slight  intensity  noticeable  in 
the  parents  individually,  combine  and  obtain  through  this  combi- 
nation such  a  force  in  the  offspring  that  a  definite  characteristic 
is  imparted  to  the  latter.  The  qualities  arising  by  means  of 
such  combination-processes  in  the  germs  are  not  inherited  as 
such,  as  they  never  existed  in  this  form  in  the  ancestors;  but  as 
they  consist  of  distinguishing  features  of  the  parental  germ-cells 
they  must  have  been  transmitted  from  the  ancestors  to  their 
descendants;  in  such  a  case  the  appearance  of  new  qualities  in 
the  children  is  only  an  apparent  one.  It  is  even  conceivable 
that  a  certain  peculiarity  has  not  come  to  light  in  the  consan- 


CONSANGUINITY  IN  MARRIAGE  81 

guineous  parents  because  itwas  suppressed  by  other  predominant 
characteristics;  the  latter  being  less  prominent  in  the  children 
the  parental  peculiarity  not  observable  in  the  parents  becomes 
strikingly  so  in  the  offspring.  The  question  may  therefore  be 
simplified  and  the  probability  of  obtaining  decisive  results  from 
investigation  will  accordingly  be  the  greater,  if  we  begin  by 
taking  into  consideration  only  the  augmentation  of  the  effects 
of  heredity  through  consanguinity,  and  disregarding,  on 
account  of  its  being  outside  the  domain  of  ordinary  rieredity, 
the  organic  degeneration  in  the  descendants  supposed  to  result 
exclusively  from  the  absence  of  foreign  blood. 

Moreover  the  examination  into  the  consequences  of  con- 
sanguineous marriages  has  hitherto  been  frequently  conducted 
for  certain  purposes,  or  only  partially,  from  limited  and  one- 
sided standpoints,  on  the  basis  of  restricted  statistics  or  his- 
torical observations  of  the  civilisation  of  self-contained  nations 
and  castes  and  of  the  experiences  of  agriculturists  and  breeders. 
It  is  therefore  not  surprising  that  as  soon  as  the  results  thus 
obtained  were  generalised  and  made  to  apply  to  all  conditions 
without  exception,  mistakes  often  arose.  But  the  question  as 
to  the  nature  and  consequences  of  consanguinity  can  only  be 
solved  in  a  manner  embracing  all  the  points  of  view  hitherto 
considered  separately,  and  that  not  exclusively  with  regard  to 
one  particular  species  of  organism,  say,  man  alone.  This  must 
be  done  by  comparative  investigations  comprising  the  whole 
organic  world.  A  well-directed  combination  of  all  the  stand- 
points from  which  the  problem  has  hitherto  been  studied  is 
accomplishable,  and  the  widest  possible  survey  obtainable  by 
considering  the  marriage  of  blood-relations  as  a  special  case 
of  in-and-in-breeding. 

In-and-in-breeding  (E,ndogamy).— In  opposition  to 
the  natural  selection  as  it  proceeds  in  nature  by  means  of  the 
struggle  for  existence  we  call  in-and-in-breeding  (or  endogamy) 
— the  further  propagation  among  themselves  of  the  cross- 
products  of  various  races.  In  this  way  it  is  possible  with  cer- 
tainty to  perpetuate  in  the  course  of  a  few  generations  qualities 
produced  in  the  cross-breed.  The  general  admixture  in  one  and 
the  same  race  may,  according  to  Reibmayr,  be  called  "far 


82  HEALTH,  DISEASE,  MARRIAGE 

in-and-in-breeding";  that  inside  of  a  small  circle  of  individuals 
of  the  same  race  "near  in-and-in-breeding."  In-and-in-breeding 
produces  refinement;  but  morbid  characteristics  common  to  both 
parents  are  naturally  also  capable  by  (near)  in-and-in-breeding 
of  aggravation  and  accumulation.  The  selection  from  all  the 
qualities  by  the  in-and-in-breeding  depends  therefore  probably 
also  only  on  an  augmentation  of  the  effect  of  heredity.  Con- 
sanguineous breeding  is  entirely  subject  to  in-and-in-breeding, 
for  it  is  evident  that  the  fixation  of  certain  characteristics  is 
effected  much  more  quickly  by  the  pairing  of  demonstrable 
blood-relations.  The  stigma  of  incest  which  is  accountable  for 
a  great  deal  of  the  existing  prejudice  against  consanguineous 
marriages  therefore  falls  to  the  ground. 

Blood-relationship  and  its  degrees. — Relation- 
ship (blood-relationship)  is  according  to  the  ideas  prevalent 
among  civilised  nations  with  respect  to  family,  the  connection 
existing  between  several  persons  on  the  basis  of  procreation 
or  descent  and  therefore  on  that  of  community  of  "blood."  The 
term  "blood"  means  in  this  connection  the  sum  of  all  the  peculiar 
characteristics  and  faculties  inherent  in  all  these  persons  (the 
breed),  but  especially  all  the  in-and-in-breeding  phenomena. 
The  expression  "direct  line"  means  the  relationship  of  those 
persons  of  whom  one  descends  from  the  other.  Where  indi- 
viduals are  not  related  in  a  direct  line  but  are  descendants  of  the 
same  third  person  we  speak  of  "collateral  relationship."  Blood- 
relations  born  from  the  same  parents  are  full  brothers  and 
sisters;  where  they  have  only  one  parent  in  common,  they  are 
half-brothers  or  half-sisters,  that  is,  consanguineous  where  the 
common  parent  is  the  father,  and  uterine  where  the  common 
parent  is  the  mother.  "Distant"  relations  begin  according  to 
the  "Sachsenspiegel"  (a  mediaeval  law-book)  with  the  children 
of  brothers  and  sisters.  The  collateral  lines  are  either  "like" 
when  each  of  the  lines  coming  into  consideration  has  the  same 
number  of  removes  (cousins  f.  i.  are  said  to  be  related  in  a  like 
line)  or  "unlike"  (as  f.  i.  the  relationship  between  uncle  and 
nephew).  The  nearness  of  relationship  is  determined  by  the 
number  of  removes  present  between  two  persons.  According  to 
Roman  law  there  are  as  many  removes  between  two  relatives 


CONSANGUINITY  IN  MARRIAGE  83 

as  there  are  births  between  them.  The  German  Civil  Code 
(§  1589)  has  adopted  the  same  principle.  It  declares  father 
and  son  as  related  to  each  other  in  the  first  degree  of  the  direct 
line,  grandfather  and  grandchild  in  the  second  degree  of  the 
direct  line,  brother  and  sister  in  the  second  degree  of  the  col- 
lateral line,  and  uncle  and  nephew  in  the  third  degree  of  the 
collateral  line.  The  canonical  reckoning  of  collateral  relation- 
ship takes  into  consideration  the  distance  from  the  common 
ancestor;  canon-law  takes  therefore  only  one  line,  but  always 
the  longer  one,  that  is  the  procreations  as  far  as  the  common 
founder.  According  to  canon-law,  brother  and  sister  are 
related  in  the  first  degree,  uncle  and  nephew  in  the  second. 
There  may  also  be  "double  relationship"  both  in  the  direct  and 
in  the  lateral  line.  In  the  first  case  it  may  arise  by  the  descent 
of  one  person  from  another  through  two  lines  of  generation 
(f.  i.  great-grandfather  and  great-grandchild,  where  the  latter 
springs  from  the  union  of  two  cousins).  Double  relationship  is 
present  in  the  lateral  line  where  two  persons  are  descended  from 
a  common  third  through  more  than  two  lines  of  generation  or 
from  two  common  ancestors  (mothers). 

This  is  the  place  to  mention  two  propositions  discussed  by 
Lorenz.  According  to  him,  every  individual  has  two  parents 
but  not  everybody  has  4  grandparents  and  8  great-grandparents, 
and  very  few  people  indeed  are  able  to  supply  any  information 
about  their  16  ancestors  and  32  great-ancestors.  With  regard 
to  these  there  are  only  pedigrees  which  prove  that  in  the  upper 
lines  of  ancestors  the  same  persons  appear  several  times  as 
the  ancestors  of  one  and  the  same  descendant.  This  happens  to 
a  greater  extent  wherever  marriages  occur  among  near  relatives 
but  also  much  more  than  is  generally  assumed  even  among  the 
descendants  of  different  families.  The  proportion  of  the  num- 
ber of  ancestors  theoretically  to  be  expected  to  the  number 
actually  present  expresses  the  numerical  loss  of  ancestors.  In 
the  uppermost  ancestral  lines  we  ought  to  possess  an  extraordi- 
narily large  number  of  ancestors,  but  in  reality  the  number  of 
ancestors  in  the  uppermost  lines  is  apparently  a  very  small  one 
indeed  (we  are  hardly  all  descendants  of  Adam  and  Eve  but 
spring  presumably  from  a  limited  number  of  ancestors)  and  the 


84  HEALTH,  DISEASE,  MARRIAGE 

loss  in  ancestors  is  therefore  an  immense  one.  As  it  is  at  present 
generally  the  case,  the  number  of  ancestors  of  any  one  descend- 
ant is  much  too  small,  because  the  number  of  people  who  really 
do  cross  is  on  account  of  such  circumstances  as  race,  nationality, 
religion,  domiciliation,  difference  of  social  position,  etc.,  etc., 
comparatively  a  very  limited  one.  The  greatest  possible 
increase  in  the  number  of  ancestors  is  caused  by  racial  admix- 
ture. Everything  depends  therefore  on  in-and-in-breeding.  An 
exact  definition  of  the  term  "in-and-in-breeding"  is  really 
possible  only  on  the  basis  of  a  mathematical  calculation  of  the 
loss  in  ancestors. 

The  complemental  value  of  the  loss  in  ancestors  is 
the  sum  of  heredity.  To  the  descendants  of  a  marriage 
between  cousins  the  loss  in  ancestors  in  2/8 ;  the  sum  of 
heredity  is  therefore  6/8.  This  means  that  the  children  of 
such  a  marriage  have  only  6  great-grandparents  instead  of 
8,  and  that  they  consequently  inherit  their  qualities  from  6 
such  great-grandparents  only.  But  the  sum  of  heredity  of 
each  of  the  8  ancestors  is  to  be  reckoned  as  1/8.  According  to 
Peipers  this  method  of  calculation  causes  difficulties  only  where 
there  are  deviations  within  the  line-succession,  that  is,  where  a 
pair  of  ancestors  appears  in  different  lines.  The  loss  in  ancestors 
to  the  descendants  of  a  marriage  between  uncle  and  niece,  for 
instance,  is  reckoned  to  be  equal  to  that  of  cousins,  although 
this  seems  incongruous.  Peipers  confines  himself  to  giving  a 
short  account  of  how  the  value  of  the  sum  of  heredity  is  to  be 
calculated  from  genealogical  points  of  view: 

Father  and  daughter    .     .     Sum  of  heredity  =     1/2 

Brother  and  sister    ...  =2/4 

Uncle  and  niece  ...."""  =     1/4 

Double  cousins    ...."""  =    4/8 

Cousins =6/8 

Second  cousins     ....  =14/16 

The  designation  in  degrees  hitherto  adopted  is  not  of  much 
use,  because,  as  we  have  seen,  most  variable  methods  of  calcula- 
tion have  been  and  can  be  applied.  In  Germany  there  are  two 
legal  "computations,"  the  juridic-Roman  and  the  canonic. 


CONSANGUINITY  IN  MARRIAGE  85 

Incest. —  We  have  already  defined  the  pairing  of  demon- 
strable blood-relations  as  consanguineous  breeding.  This  con- 
sanguineous breeding  becomes  incestuous  breeding  if  parents 
pair  with  their  children  or  grandchildren,  brothers  with  sisters, 
or  grandchildren  with  one  another.  Where  the  relationship  is 
not  too  close  we  speak  of  family-breeding  (marriage  between 
relatives) . 

Prohibition  of  marriage  between  blood-rela- 
tions.— It  may  be  said  that  the  prohibition  of  consanguineous 
marriages  is  the  rule  not  only  among  civilised  but  also  among 
uncivilised  nations.  Respecting  the  latter  two  customs  con- 
nected with  marriage  and  dating  from  ancient  barbarian  times 
are  quoted  by  those  opposed  to  consanguinity,  namely  exogamy 
and  wife-capture  (Australia,  northern  races  [O.  Magnus]), 
the  prohibition  among  the  Indian  Brahmins  to  marry  women 
belonging  to  their  own  tribes,  the  rape  of  the  Sabbinian  women, 
the  abduction  of  Shilo's  daughters  by  Benjamin's  men  spoken 
of  in  the  Bible,  the  preservation  of  some  "form  of  wife-capture" 
by  various  nations  of  all  kinds  of  races,  the  prohibition  to 
marry  a  person  bearing  the  same  family-name  existing  among 
the  Chinese,  in  the  highlands  of  Scotland  and  among  the  peoples 
in  the  Indian  Archipelago,  etc.,  severe  punishment  of  incest. 
(Buginese,  Pasemakers.) 

It  would  be  however  very  difficult  to  prove  that  exogamy 
f.  i.  was  nothing  else  but  a  reform-measure  intended  to  put  an 
end  to  marriages  between  blood-relations  when  it  was  found 
that  they  have  injurious  consequences  (Morgan,  Main,  Schiller- 
Titz).  It  probably  originated  mainly  as  a  result  of  the  oldest 
condition  of  society  and  of  the  family  (communal  marriage, 
polyandry,  marriage  with  the  brother's  widow,  scarcity  of 
women  among  some  tribes,  etc.).  The  matriarchate  associated 
with  such  a  primitive  family-system  would  even  frustrate  the 
intention  to  eliminate  consanguineous  marriages;  for  half- 
brothers  and  half-sisters  on  the  father's  side  would  be  able  to 
marry  each  other,  being  of  different  tribes.  As  a  matter  of  fact 
this  kind  of  marriage  is  seen  in  different  nations,  even  in  such 
which  have  already  discarded  exogamy  or  restricted  it  to  por- 
tions of  tribes,  as  f.  i.  among  the  Howas  (Schiller-Titz)  : 


86  HEALTH,  DISEASE,  MARRIAGE 

brothers  and  sisters  may  marry  each  other,  but  they  must  not 
have  the  same  mother. 

But  it  would  mean  going  too  far  were  we  to  deny  altogether 
that  an  empirically  gained  conviction  of  the  injuriousness  of 
consanguineous  marriages  played  here  any  part.  The  Arabs, 
f.  i.  as  Schiller-Titz  shows,  are  perfectly  familiar  with  this 
theory  of  injuriousness.  A  saying  of  the  Haditt — the  sacred 
tradition  of  the  Arabs — runs:  "Marry  from  among  strangers, 
so  that  thou  dost  not  beget  a  weak  offspring."  Later  law-books 
also  give  expression  to  this  view,  f.  i.  that  of  Badjuri,  the  com- 
mentator of  the  Ibn-Quasim.  He  says:  "Whoever  wishes  to 
obtain  a  noble  breed  must  marry  from  a  foreign  country,  just 
as  one  will  obtain  good  fruit  from  a  branch  grafted  into  a 
foreign  trunk."  Similarly  marriage  with  a  "bint-amm"  (the 
daughter  of  an  uncle  on  the  father's  side)  is  also  exhorted 
against. 

The  main  reason  of  the  laws  enacted  by  civilised  nations 
against  marriage  between  nearest  relatives  is  probably  also  not 
to  be  found  every  time  in  the  intention  to  prevent  a  degenera- 
tion of  the  species.  Legislators,  oecumenical  councils,  etc.,  only 
very  rarely  express  themselves  directly  in  that  sense.  Pope 
Gregory  I.  (ob.  605)  writes  for  instance  to  the  Benedictine 
monk  Augustinus  who  was  sent  out  to  convert  the  Anglo- 
Saxons:  "A  secular  law  of  the  Roman  State  permits  marriage 
between  the  son  and  daughter  of  a  brother  and  sister.  But 
experience  teaches  that  the  offspring  of  such  marriages  cannot 
thrive."  This  opinion  of  the  injuriousness  of  consanguineous 
marriages  is  expressed  even  more  distinctly  in  the  Capituloria 
regum  francorum.  There  it  is  said  that  from  marriages  between 
relatives  spring  blind  children  and  cripples,  lame  and  blear- 
eyed,  or  offspring  affected  with  other  similar  infirmities.  Nor 
have  the  laws  of  civilised  States  which  have  from  times  imme- 
morial endeavoured  to  restrict  marriages  between  blood-rela- 
tions proceeded  exclusively  from  anti-sanguinistic  motives.  This 
is  seen,  to  begin  with,  in  the  great  difference  of  these  restrictions 
as  regards  the  degree  of  blood-relationship.  Moreover,  there  is 
sufficient  direct  testimony  to  prove  that  these  laws  have  princi- 
pally been  passed  for  the  purpose  of  preventing,  by  the  sharp 


CONSANGUINITY  IN  MARRIAGE  87 

prohibition  of  marriage  between  blood-relations,  prostitution 
among  families,  the  accumulation  of  too  large  fortunes  by  a 
limited  number  of  people,  etc.,  etc. 

Let  us  now  examine  into  these  laws  regarding  consan- 
guineous marriages  which  have  existed  among  the  highest 
civilised  nations  in  history  and  are  at  present  in  force  in  the 
most  important  European  States.  Relationship  appears  here  as 
a  relative  impediment  to  marriage. 

Moses  prohibited  marriage  between  blood-relations  of  the 
nearest  degrees  (with  parents,  grandchildren,  full  and  half- 
sisters,  sisters  of  father  or  mother)  but  was  tolerant  with  regard 
to  marriages  between  cousins  and  between  uncle  and  niece. 
The  Mosaic  law  demands  categorically  that  daughters  shall 
marry  only  from  among  the  family  to  which  they  belong;  this 
was  an  indirect  incitement  to  marriage  between  blood-relations. 
Among  the  Spartans  marriage  between  relatives  in  the  direct 
line  was  prohibited.  In  Athens  the  marriage  of  near  relations 
was  in  certain  definite  cases  not  permitted;  on  the  other  hand 
consanguineous  marriage  became  a  duty  when  a  citizen  left 
only  an  heiress,  as  the  latter  was  in  such  a  case  compelled  to 
marry  the  nearest  of  her  relatives  so  that  the  fortune  should 
remain  in  the  family.  The  Roman  law  contained  prohi- 
bitions of  marriage  between  ascendants  and  descendants,  be- 
tween persons  standing  in  the  "respectus  parentale"  (that 
is,  the  relation  between  uncle  or  aunt  on  the  one  side  and 
nephew  or  niece  on  the  other),  and  between  brothers  and 
sisters. 

Canon-law  introduced  severer  regulations  and  prohibited 
every  marriage  in  the  direct  line  between  ascendants  and 
descendants,  and  in  the  collateral  line  not  only  marriages  between 
brothers  and  sister  and  between  cousins,  but  even  those  between 
removed  cousins  (sobrini)  up  to  the  6th  degree,  inclusive,  of 
relationship  according  to  Roman  computation. 

Since  the  eighth  century  the  Church  has  endeavoured  to 
restrict  still  more  marriages  between  blood-relations  and  pro- 
hibited the  same  gradually  up  to  the  7th  degree  of  the  Germanic 
calculation  of  relationship,  which  differs  from  the  Roman 
method  in  so  far  as  it  does  not  like  the  latter  include  the  neces- 


88  HEALTH,  DISEASE,  MARRIAGE 

sary  number  of  births  for  the  creation  of  the  relationship  but 
only  the  births  of  one  side,  and  if  the  two  are  not  alike  those 
of  the  longer  side  up  to  the  common  ancestor.  If  therefore  two 
persons  are  according  to  the  canon-law  reckoning  of  the  degree 
of  relationship  (computatio  canonica,  or  really  computatio 
Germanica)  related  to  one  another  in  the  yth  degree,  they  are 
according  to  Roman-law  reckoning  (computatio  civilis)  related 
in  the  I4th  degree.  Canon-law  thus  permitted  marriage  from 
the  1 4th  degree  of  Roman  computation.  Innocent  III.,  however, 
restricted  again  (1215)  the  prohibitions  up  to  the  4th  degree 
of  canonical  computation,  and  this  law  is  at  the  present  day  in 
force  in  the  Catholic  Church;  but  dispensation  is  (easily) 
obtained  for  the  3d  and  4th  degrees,  and  even  for  the  2d. 
According  to  Protestant  Church-law  the  direct  line  is  in  all 
cases  an  annihilating,  indispensable  and  public  impediment  to 
marriage,  the  collateral  line  is  so  in  the  first  degree,  that  is  with 
respect  to  brothers  and  sisters.  There  also  used  to  be  a  dis- 
pensable impediment  to  marriage  in  the  case  of  "respectus 
parentelae." 

The  Koran  prohibits  marriages  between  relations. 

The  German  Imperial  Code  (Deutsches  Reichsgesetz)  of 
1875  recognises  the  following  impediments  to  marriage: 
relationship  in  the  ascending  and  descending  line,  the  relation- 
ship between  full  and  half  brothers  and  sisters.  Marriages 
between  cousins,  between  uncle  and  niece,  and  between  aunt 
and  nephew  are  by  German  law  distinctly  permitted.  In  Russia 
the  secular  legislation  is  like  that  of  Canon-law  (previous  to 
Innocent  III.)  and  it  forbids  marriage  between  blood-relations 
up  to  the  7th  degree.  In  Switzerland  marriages  between  cousins, 
uncle  and  niece,  and  aunt  and  nephew  are  distinctly  prohibited 
— that  is,  without  dispensation.  In  Austria  also  these  marriages 
are  prohibited,  but  among  the  Jewish  subjects  of  that  country 
marriage  between  cousins  is  allowed.  In  England,  France,  Italy, 
Holland  and  Roumania  marriages  between  relatives  of  the 
3d  degree  (uncle  and  niece,  aunt  and  nephew)  are  either  pro- 
hibited altogether  or  permitted  only  by  dispensation,  but  those 
between  relatives  of  the  4th  degree  (cousins)  are  permitted. 

Modern    legislations    therefore    materially    differ    on    the 


CONSANGUINITY  IN  MARRIAGE  89 

point;  the  two  extremes  are  formed  by  the  German  and  the 
Russian. 

Historical  and  ethnographical  remarks  on 
endogamy  and  on  marriage  between  relations 
(brothers  and  sisters). — In  the  attempt  to  grasp  the 
problem  of  the  origin  of  human  civilisation  and  to  discover 
historical  foundations,  too  much  influence  has  been  attributed 
to  one-sided  definite  factors.  Whereas  f.  i.  Buckle  makes  it 
appear  that  the  fate  of  the  human  race  is  dependent  entirely 
on  soil  and  climate,  A.  Reibmayr  and  Houston-Chamberlain 
emphasize  exclusively  the  effect  of  in-breeding  and  of  race- 
mixture.  There  are  doubtless  also  other  external  influences  and 
inner  forces  concerned  in  the  matter  which  have  perhaps  hitherto 
received  no  consideration.  The  investigation  into  the  conse- 
quences of  consanguineous  marriages  cannot  therefore  expect 
to  gain  overmuch  from  mere  historical  retrospects  and  analogies. 
Historical  evidence  is  in  this  respect  far  too  different  from 
scientific  proofs  inasmuch  as  the  former  does  occasionally, 
at  least  in  such  questions  as  those  concerning  us  here,  allow  a 
little  too  much  latitude  to  subjective  tendency  and  the  supple- 
menting phantasy.  But  with  regard  to  the  enormous  extent  of 
our  problem  and  indirectly  also  with  regard  to  its  importance 
we  can  learn  something  from  historical  observations.  The  more 
so,  as  statistics  especially  are  not  of  any  more  decisive  benefit 
to  our  subject  than  anthropological  and  ethnographical  con- 
siderations which,  it  must  be  admitted,  are  probably  of  greater 
consequence  than  purely  historical  conclusions. 

Where  no  in-breeding  is  adopted  no  distinct  types  at  all  of 
animal  or  human  races  are  produced ;  and  absolutely  noble  races 
can  only  be  preserved  by  incessant  breed-selection.  The  conse- 
quence of  long-continued  near  in-breeding  is  a  growing  ten- 
dency to  degeneration.  The  bad  influences  become  apparent  as 
a  rule  very  slowly  and  only  in  the  course  of  several  generations; 
hence  why  they  frequently  escape  observation  in  a  single  gen- 
eration. 

Historically  it  appears  that  man  has  always  practised 
in-and-in-breeding,  unless  special  causes  making  the  struggle  for 
existence  vastly  severer  (over-population,  geological  disturbances, 


90  HEALTH,  DISEASE,  MARRIAGE 

etc.)  produced  temporarily  a  complete  interruption.  It  would 
even  seem  that  civilisation  has  constantly  kept  pace  with  the 
satisfaction  of  the  desire  to  breed-in-and-in  prevalent  among  the 
hordes  and  nations  which  made  their  mark  in  history,  with  the 
separation  of  in-bred  castes  and  the  avoidance  of  extensive 
crossing.  Thus  there  arise  not  only  physical  characteristics 
but  also  important  mental  qualities  which  are  the  basis  of  pre- 
domination. Periods  of  more  intensive  admixture  generally 
exhibit  want  of  distinguishing  features.  (  Reibmayr.)  On  the 
other  hand  pure  and  prolonged  preservation  of  an  absolutely 
strict  in-breeding  principle  assists  in  producing  a  crystallisation 
of  the  main  racial  peculiarities  and  prevents  further  progress. 
A  complete  suppression  of  the  natural  selection  leads  finally, 
especially  in  the  principal  castes,  to  bodily  and  mental  deteriora- 
tion, that  is,  to  an  hereditary  disturbance  of  the  correlation 
between  the  single  organs  of  the  body  and  of  the  mind. 

Just  as  great  progress  in  the  civilisation  of  any  single  nation 
is  apparently  impossible  without  a  close  in-breeding,  so  man- 
kind in  general  would  not  make  any  marked  advance  without 
the  inter-mixture  of  civilised  nations  with  others  physically 
superior  to  them  though  culturally  on  a  lower  level.  The  effect 
of  such  an  intermixture  is  in  the  first  instance  the  conservation 
and  regeneration  of  the  physical  strength  of  the  races,  and  in  the 
second  a  transformation  of  mental  faculties.  Where  two  dis- 
tinct races  intermix  the  result  is,  to  begin  with,  something 
heterogeneous.  Some  original  characteristics  however  are  not 
altered  but  transmitted  to  the  offspring;  and  the  tendency  of 
the  latter  to  revert  to  parental  forms  lasts  for  some  time.  The 
formation  of  extreme  qualities  is  also  delayed.  But  after  having 
conquered  this  reversion,  and  after  a  short  retrogression  in  the 
state  of  civilisation  later  generations  attain  higher  degrees  of 
culture  comparatively  much  more  rapidly. 

The  impartial  observer  will  therefore  direct  his  attention 
to  the  "optimum"  of  in-breeding;  beginning  with  the  possibility 
of  procreation  under  equal  pairing  the  chart  reaches  a  certain 
height  in  the  excellence  of  the  offspring  which  shows  a  certain 
similarity  to  that  of  the  procreators,  and  then  sinks  towards 
the  other  extreme  which  renders  procreation  impossible  (maxi- 


CONSANGUINITY  IN  MARRIAGE  91 

mal  similarity  of  the  procreators,  equality  of  generations) .  The 
question  as  to  the  latitude  of  the  "optimum"  cannot  at  present 
be  definitely  answered.  The  conditions  are  probably  not  the 
same  in  man  as  in  animals;  in  plants  they  are  certainly  different. 
The  classical  endogamous  nations  of  ancient  times 
are  above  all  the  Egyptians,  the  Jews,  and  the  Aryan 
Indians.  The  whole  national  State  and  legislation  of  the 
Jews  f.  i.  were  based  upon  the  principle  of  in-and-in- 
breeding.  The  descendants  of  the  tribe  of  Levi  became 
the  leading  caste.  But  as  the  priests  had  no  share  in  the 
inheritance  of  Israel,  they  were  not  as  completely  sepa- 
rated from  the  people  as  other  ruling  castes  which  on 
account  of  the  riches  they  acquired  were  a  class  abso- 
lutely apart  from  others.  The  first-born  from  among 
the  people  belonged  to  the  Lord  and  had  to  be 
redeemed;  they  seem  therefore  to  have  been  destined  to 
make  up  the  full  number  of  the  Levites  in  case  of  the 
diminution  of  the  latter.  Provision  was  thus  wisely  made 
for  a  necessary  selection  and  for  fresh  blood.  The  duty 
of  Israel  to  keep  themselves  holy  by  strong  seclusion 
from  everything  pagan  became  more  and  more  a  dogma. 
The  exile,  like  the  sojourn  in  Egypt,  was  a  practical 
school  of  strict  separateness.  The  laws  relating  to 
in-and-in-breeding  underwent  codification  after  the 
return  from  the  Babylonian  captivity  (944  B.  C.).  The 
community  assumed  the  obligation  to  prevent  all  mixed 
marriages  with  individuals  not  belonging  to  it.  Women 
and  children  belonging  to  foreign  tribes  were  turned 
away.  That  Judaism  is  still  existing  at  the  present  day 
is  partly  due  to  the  strict  retention  of  the  in-breeding 
principle  by  the  later  Pharisees  and  their  successors  the 
Rabbis.  With  such  a  comparatively  small  nation  it 
almost  follows  as  a  consequence  that  in  the  post-exile 
period  and  especially  afterwards  during  the  dispersion 
all  the  Jews  in  certain  places  must  have  been  related 
to  each  other  and  consanguineous  marriages  must  have 
been  quite  common.  Thus  Tobit  advises  his  son  Tobias 
(at  the  time  of  the  Maccabfeans?)  to  take  unto  himself 


92  HEALTH,  DISEASE,  MARRIAGE 

a  wife  from  among  his  relations,  according  to  Jewish 
custom.  But  it  was  not  permitted  that  a  man  should 
marry  his  mother,  step-mother,  sister  or  step-sister. 
After  the  final  dispersion  of  the  Jews  there  were  only 
two  countries  in  which  they  could  intermix  to  a  rela- 
tively greater  extent,  namely  in  Mahomedan  Spain  and 
in  Poland.  In  Spain  this  intermixing  took  place  with 
kindred  Semitic  or  half-semitic  races.  Reibmayr  is 
inclined  to  attribute  the  circumstance  that  the  Sephardim 
who  sprang  from  this  intermixture  are  a  physically  good- 
looking  and  mentally  capable  race,  to  the  many  mar- 
riages entered  into  with  Arabs,  etc.  On  the  other  hand 
he  believes  that  the  inclination  of  the  Polish  Jews  to 
encourage  intermixing  must  have  been  very  small  (under 
King  Kasimir  the  Great  the  Jews  were  relatively 
well-off),  or  else  the  Ashkenazim  would  in  spite  of  an 
eventual  mental  retrogression  have  become  at  least 
physically  stronger  and  finer-looking.  This  evidence  is 
however  by  no  means  exhaustive.  The  Sephardim  have 
had  since  the  dispersion  a  happier  period  than  any  other 
portion  of  the  Jews,  and  this  cannot  have  been  without 
some  effect  upon  their  race;  whereas  in  the  case  of  the 
Polish  Jews  not  only  in-breeding,  but  poverty  and 
its  consequences  must  have  played  a  very  considerable 
and  fateful  part  in  their  degeneration.  Upon  the  whole 
it  may  be  said  that  the  Jewish  nation  which  has  on 
account  of  its  hard  struggle  for  existence  been  constantly 
subject  to  a  certain  weeding-out  process,  and  whose  lead- 
ing caste  has  not  kept  absolutely  aloof  from  the  bulk 
of  the  people,  has,  during  its  course  of  a  history  extend- 
ing over  more  than  100  generations,  received  from  its 
in-and-in-breeding  policy  more  good  than  harm:  at  the 
worst  it  may  be  said  to  have  become  a  markedly  fixed 
type  with  a  striking  hereditary  intensity.  The  wonder 
really  is  that  the  Jewish  nation  exists  yet  at  all. 

In  more  recent  and  modern  times  the  value  of  pure 
in-breeding  may  be  judged  from  the  English  and  the 
Japanese.  On  account  of  its  insular  position  England  is 


CONSANGUINITY  IN  MARRIAGE  93 

cut  off  from  the  rest  of  the  world.  The  last  serious 
invasion  took  place  800  years  ago;  since  then  only  a 
few  thousand  Netherlanders  and  Huguenots  (therefore 
kindred  blood)  have  been  added,  and  thus  the  strongest 
present-day  race  in  the  world  has  sprung  up.  Perhaps 
the  same  thing  has  happened  in  Japan  where  there  was 
also  at  first  a  good  intermixture;  afterwards  insular 
seclusion  was  an  important  element  in  the  formation  of 
the  race.  The  Japanese  are  the  most  important  nation, 
at  least  among  the  Mongolians. 

Instructive  in  this  connection  is  perhaps  also  Cham- 
berlain's reference  to  the  Slavs.   Qualified  historians  do 
not  attribute  to  them,  in  spite  of  their  great  ability,  any 
creative  faculty  or  executive  perseverance.     The  cause 
is  supposed  to  lie  in  the  fact  that  the  majority  of  this 
large  race  has  through  intermixture  with  another  race 
lost    the    physical    characteristics    of    their    ancestors 
(who  were  identical  with  the  old  Germans),  and  at  the 
same  time  the  mental  qualities  as  well.   The  decline  of 
prominent  racial  peculiarities  through  intermixture  is 
still  more  apparent  in  Rome  since  Sulla  and  Marius, 
in  the  South  American  States  (Peru),  etc. 
Peipers  calls  attention  to  the  fact  resulting  from  the  observa- 
tions and  conclusions  of  Lorenz,  that  there  is  everywhere,  and 
especially  in  rural  districts,   a  far  greater  amount  of  blood- 
relationship  and  common  ancestry  than  one  is  generally  inclined 
to  admit.   The  bondage  of  former  centuries  did  not  only  mean 
an  attachment  to  the  soil ;  it  also  compelled  marriage  with  fellow 
bond-servants  of  the  opposite  sex  who  were  subject  to  the  same 
bond-master.     As    a    consequence    there    arose,    according   to 
Lorenz,  relationships  of  unheard-of  complication  and  nearness 
just  among  those  classes  of  people  of  whom  one  likes  to  believe 
that  they  possess  an  inexhaustible  material  of  mixed  blood.  The 
inhabitants  of  most  rural  places  in  Europe  are  related  among 
themselves  a  hundred  and  a  thousand  times. 

But  those  who  lay  particular  stress  on  the  dangers 
of  in-and-in-breeding  are  also  not  short  of  examples 
which  seem  to  prove  that  the  unconscious  popular 


94  HEALTH,  DISEASE,  MARRIAGE 

instinct  interferes  here  for  purposes  of  correction.  Such 
an  example  is  furnished  by  the  Iroquois  of  North 
America.  These  Indians  are  divided  in  a  number  of 
clans,  which  represent  smaller  nations  of  the  entire 
nation.  Each  of  these  clans  elects  its  own  chieftain,  its 
members  are  heirs  to  each  other,  and  each  possesses  its 
own  symbol  or  totem.  As  regards  marriage  there  is  a 
fixed  law.  Each  clan  consists  of  many  marriages.  These 
have  from  times  immemorial  been  arranged  in  the  fol- 
lowing way.  No  young  man  or  maiden  marries  into  his 
or  her  own  clan.  Marriages  can  under  all  circumstances 
only  be  entered  into  between  members  of  two  different 
clans.  Each  marriage  means  therefore  an  addition  of 
fresh  blood.  Children  owe  allegiance  to  their  mother's 
totem  ("Maternal  jurisdiction").  Father  and  mother 
remain  in  her  clan.  A  similar  method  of  totemism  has 
(according  to  Fison  and  Howitt)  also  developed  f.  i. 
among  the  natives  of  Coopers  Creek  in  South  Aus- 
tralia. 

Taking  everything  into  consideration  it  would  therefore 
appear  that  anthropologico-historical  observations  are  rather 
inclined  to  prove  that  provided  the  quality  of  the  material  be 
good  the  production  of  noble  races  depends  largely  on  the  laws 
of  breeding-in  and  weeding-out,  and  only  to  a  small  extent  upon 
an  admixture  of  blood,  limited  both  as  to  time  and  method. 
The  promiscuity  desired  by  Virchoiu,  Ratzel  and  others  is  in 
any  case  more  dangerous  than  in-breeding. 

History,  both  ancient  and  modern,  and  ethnology  teach  us 
even  by  some  examples  that  nations  and  castes  have  been  able 
to  propagate  themselves  for  longer  or  shorter  periods  by  con- 
sanguineous marriages  without  exhibiting  any  gross  signs  of 
degeneration. 

I  will  take  here  no  notice  of  the  incestuous  unions  between 
father  and  daughter,  mother  and  son,  brother  and  sister, 
spoken  of  in  the  mythologies  and  legends  of  uncivilised  nations. 
A  detailed  description  of  these  will  be  found  in  the  work  of 
Schiller-Titz.  But  it  is  necessary  to  mention  that  among  great 
nations  consanguineous  marriages  were  not — and  are  not — only 


CONSANGUINITY  IN  MARRIAGE  95 

not  forbidden,  but  that  they  were — and  are— entered  into  with 
predilection.  The  old  Egyptians  f.  i.  knew  of  no  impediments 
to  marriage;  their  Kings  (especially  the  Ptolemaei)  married  not 
infrequently  their  own  sisters ;  thus  Cleopatra  was  the  daughter 
of  a  marriage  between  brother  and  sister,  the  grandchild  of 
another  similar  marriage  and  the  grandchild  of  Berenice  who 
was  herself  both  niece  and  sister  of  her  husband.  Among  the 
ancient  Persians  also,  brothers  and  sisters  used  to  marry  each 
other,  and  so  did  father  and  daughter,  mother  and  son.  Descent 
from  such  marriage  was  even  a  condition  of  admission  to  the 
priesthood.  The  Athenians  likewise  permitted  marriages 
between  nearest  relatives.  Finally  the  ancient  Peruvians  also 
were  in  the  habit  of  marrying  their  mothers,  sisters  and  daugh- 
ters. They  had  a  law  in  force  with  regard  to  their  ruling 
princes  according  to  which  the  Inka  was  allowed  to  marry  no 
one  else  but  his  own  sister.  This  is  said  to  have  been  continued 
during  14  generations  without  any  signs  of  degeneration  hav- 
ing been  apparent  in  the  last  Inka. 

These  examples  do  not  of  course  prove  much.  The  non- 
existence  of  a  prohibition  is  not  synonymous  with  a  great  preva- 
lence of  incestuous  marriages  among  the  bulk  of  the  people. 
But  if  the  numerical  proportion  of  consanguineous  marriages 
is  not  ascertained  exactly  it  is  also  not  possible  to  fix  their  rela- 
tion to  the  physical  ability,  mental  development  and  degenera- 
tion of  a  people. 

Schiller-Titz  enumerates  further  among  the  uncivilised 
nations,  tribes  which  live  as  yet  in  continued  consanguinity. 
(The  Baduwis  among  the  Soudanese,  the  Bataks  of  Sumatra, 
the  Arabs.)  Although  the  small  number  of  inhabitants  in  the 
interior  villages  of  the  Baduwis  which  consist  of  no  more  than 
40  households  have  propagated  themselves  for  400  years  by 
means  of  the  closest  consanguinity  they  are  said  to  form  a 
powerful  race.  According  to  Krusemann,  no  deformed  or  infirm 
are  to  be  seen  among  them.  The  Baduwis  are  further  dis- 
tinguished by  frankness  and  loyalty.  From  very  early  times  it 
has  been  the  rule  with  the  Bataks  to  marry  their  cousins,  that 
is  daughters  of  an  uncle  from  the  mother's  side,  so  that  boru- 
ni-datulang  (daughter  of  the  mother's  brother)  became  the 


96  HEALTH,  DISEASE,  MARRIAGE 

title  of  the  betrothed  and  the  wife.  Nevertheless  this  nation  is 
also  said  to  be  one  of  the  most  advanced  in  the  Indian  Archi- 
pelago. In  contrast  to  the  Malays  they  possess  a  powerful 
well-formed  muscular  system.  Marriages  with  cousins  have  also 
been  the  rule  with  the  Arabs  for  many  centuries  past. 

Whereas  other  statements  by  observers  who  proceed  from  a 
contrary  point  of  view  contradict  these  customs  of  the  Bataks 
and  Arabs  just  mentioned,  it  seems  at  least  certain  that  the 
peculiar  constitution  of  the  Baduwis  practically  enforces  general 
blood-relationship. 

Krascheninnikof  says  that  in  Kamtschatka  brothers  marry 
their  sisters,  and  Cameron  reports  the  same  with  regard  to  the 
Wangoro.  Arrago  maintains  that  in  Goam  also  brothers  often 
marry  their  sisters;  such  unions  are  indeed  considered  to  be 
most  suitable  and  natural.  Further  it  is  known  that  among  the 
Royal  families  of  Baghirmi,  Siam,  Burmah,  and  Polynesia  mar- 
riages between  brothers  and  sisters  are  not  uncommon.  Morgan 
declares  the  Malay  group-marriages  of  brothers,  full  and  col- 
lateral, with  their  sisters  as  the  most  ancient  relationship-system 
known  hitherto,  and  one  which  dates  from  pre-historic 
times. 

But  of  far  greater  importance  as  evidence  are  from  our 
point  of  view  the  often-quoted  observations  of  A.  Voisin  in 
the  commune  of  Batz  (Department  of  the  lower  Loire)  which 
lies  north  of  the  mouth  of  the  Loire  on  a  peninsula  surrounded 
by  rocks.  The  3,300  inhabitants  ( 1865)  of  the  same  have  only 
the  most  limited  intercourse  with  the  outside  world.  Marriages 
between  blood-relations  are  very  frequent  among  them.  In  1864 
there  were  there  46  consanguineous  marriages,  5  between  full 
nephews  and  nieces,  31  between  children  of  full  nephews 
and  nieces,  and  10  between  nephews  and  nieces  in  the  8th 
Roman  (fourth  canonical)  degree  of  relationship.  Never- 
theless the  state  of  health  in  young  and  old  up  to  the  third 
generation  was  an  excellent  one,  and  only  2  of  these  46  mar- 
riages proved  sterile,  the  other  44  resulting  in  172  healthy 
children. 

Schiller-Titz  gives  similar  figures  from  the  statements  of 
'Buchner  and  A.  H.  Huth  with  regard  to  the  inhabitants  of 


CONSANGUINITY  IN  MARRIAGE  97 

Schockland  (Zuyder-Zee)  and  of  a  few  fishing-villages  on  the 
Scotch  coast. 

Unfortunately  a  great  deal  depends  in  all  these  reports  on 
the  subjective  tendency  of  their  authors.  What  little  regard  for 
statistics  the  antagonists  of  consanguineous  marriages  some- 
times exhibit  may  be  seen  f.  i.  from  the  protest  of  the  Chief- 
Rabbi  of  France,  Isidor,  addressed  to  the  Academy  against  the 
assertion  of  Boudin  that  on  account  of  the  high  frequency  of 
marriages  between  blood-relations  among  the  Paris  Jews  the 
number  of  deaf-mutes  among  the  latter  is  much  higher  in  pro- 
portion than  among  Christians.  Isidor  could  only  find  9  deaf- 
mutes  in  the  whole  of  his  religious  community  of  25,000  people, 
and  Boudin  was  able  in  a  statistical  rejoinder  to  prove  only  a 
portion  of  his  assertion. 

Effects  of  crossing  and  of  self -fecundation 
in  the  vegetable  world. — I  follow  here  the  explanation 
of  A.  Schenk  (Handbuch  der  Botanik  I.  p.  7).  It  makes  a 
great  difference  as  far  as  the  result  of  the  pollination  of  plants 
is  concerned  whether  the  stigma  is  covered  with  pollen  from  the 
same  or  from  another  plant.  In  some  cases  the  pollen  of  a  plant 
has  just  as  little  effect  upon  its  own  stigmas  as  a  similar  quantity 
of  inorganic  dust.  Or  it  may  generate  utricles  which  do  not 
however  reach  the  seed-buds.  Or  the  latter  may  be  reached  and 
fecundated  but  they  only  form  poor  and  umproductive  seed- 
corns.  All  such  plants  can  be  designated  as  self-sterile.  By  far 
the  greater  number  of  plants  are  certainly  not  self-sterile,  they 
do  bring  forth  even  if  fecundated  with  their  own  pollen  a  greater 
or  smaller  number  of  seed-grains  which  are  capable  of  develop- 
ment; but  as  a  rule,  though  not  always,  the  fecundation  with 
strange  pollen  (crossing)  acts  more  favourably  than  self- 
fecundation.  Products  arising  from  the  crossing  with  a  foreign 
stock  (grown  under  different  conditions)  are  on  an  average 
larger,  stronger  and  more  fruitful.  They  offer  to  injurious  influ- 
ences or  to  the  joint  action  of  other  plants  a  much  greater  resis- 
tance than  the  products  of  self-fecundation.  And  if  separate 
plants  are  kept  through  several  generations  under  the  same  con- 
ditions and  propagated  only  by  crossing  between  them  exclu- 
sively, so  that  the  original  individual  peculiarities  become  more 


98  HEALTH,  DISEASE,  MARRIAGE 

and  more  alike  from  generation  to  generation,  the  crossing  of 
such  plants  between  them  hardly  produces  in  the  end  better 
results  than  self-fecundation.  But  if,  on  the  other  hand,  such 
plants  which  have  for  a  long  time  been  subject  to  strict  in-and-in- 
breeding,  are  crossed  with  a  fresh  stock,  the  favourable  result  of 
the  crossing  is  the  more  striking.  It  cannot  be  denied  that  it  is 
possible  in  the  vegetable  kingdom  to  observe  and  to  ascertain 
under  favourable  circumstances  the  injurious  effects  of  (close)  in- 
and-in-breeding,  seeing  that  the  succession  of  the  generations  is  a 
very  rapid  one  and  that  there  are  opportunities  to  accumulate 
a  very  large  amount  of  material  for  observation. 

It  may  perhaps  seem  presumptuous  for  me,  who  am  totally 
ignorant  of  Botany,  to  protest  against  it  that  in  the  whole  of 
animated  nature  the  importance  of  intermixture  has  been 
thought  to  be  perfectly  alike.  I  know  that  cross-planting  is  a 
favourite  and  highly  successful  method  of  florists  for  obtaining 
large,  beautiful  and  otherwise  prominent  plants;  the  whole  flora 
is  evidence  of  this.  But  the  animal  world  does  not  contain  any- 
thing universally  comparable,  and  for  this  reason  I  do  not 
believe  that  the  particularly  significant  conclusions  of  in-and-in- 
breeding  are  adaptable  without  any  restrictions  in  man  and 
animals  alike. 

In-and-in-breeding  of  animals  living  in  a  wild 
state.  Experiences  of  animal  breeders. — Breed- 
ers of  animals  generally  assume  that  it  is  possible  by  familiar 
breeding  to  fix  firmly  and  rapidly  certain  qualities  in  any  one 
breed.  If  this  is  however  continued  for  too  long,  and  especially 
in  the  form  of  incestuous  breeding,  a  weakness  in  the  consti- 
tution supervenes,  a  sort  of  over-delicacy  becomes  apparent  in 
the  animals.  Male  animals  exhibit  diminished  sexual  functions 
or  even  impotence,  females  show  decreased  fruitfulness  and  ten- 
dency to  abort,  and  young  animals  possess  less  vitality.  Family 
breeding  is  therefore  looked  upon  as  a  successful  remedy  occa- 
sionally indicated.  In  order  to  guard  against  degeneration 
through  incestuous  breeding,  breeders  use  regeneration,  that  is 
an  intermixture  with  the  blood  of  strange  animals  (of  the  same 
race)  which  possess  otherwise  the  above-mentioned  qualities  of 
the  brood. 


CONSANGUINITY  IN  MARRIAGE  99 

In-and-in-breeding  plays  an  important  part  also  in  the  case 
of  animals  living  in  a  free  state,  on  account  of  their  sociability, 
f.  i.  among  elephants.  A  remarkable  phenomenon  among  the 
latter  as  also  among  different  other  wild  animals  is  the  existence 
of  so-called  "rovers."  These  are  single  and  mature  male  ani- 
mals belonging  as  a  rule  to  no  particular  herd,  which  lead  a 
sort  of  bachelor-life.  They  form  according  to  Bolsche  by  sur- 
prising or  otherwise  seducing  females  of  other  families  a  con- 
stant reserve  army  of  occasional  regenerators. 

The  morbid  predispositions  and  pathologic 
conditions  in  man  supposed  to  be  the  results 
in  the  offspring  of  consanguinity  in  marriage. — 
The  opponents  of  consanguineous  human  marriages  base 
their  opposition  principally  upon  the  circumstance  that  mar- 
riages between  blood-relations  even  if  the  contracting  parties 
appear  to  be  normal,  often  remain  sterile,  and  that  the  chil- 
dren of  such  marriages  are  often  endowed  with  insufficient 
vitality. 

Mantegazza,  Kohl,  Waltz,  Devay  and  others  have  found 
that  10%,  and  even  18%,  of  consanguineous  marriages  remain 
sterile;  on  the  other  hand,  Darwin,  Mitchell,  Bourgeois,  Devay , 
Howe,  Remiss,  Sequin,  Dechambre,  Perier,  etc.  maintain  that 
consanguineous  marriages  are  productive  of  slightly  more  chil- 
dren, and  it  has  even  been  asserted  that  they  are  extraordinarily 
prolific.  This  contradiction  may  be  explained  in  different  ways. 
First  of  all,  propagation  depends  as  I  also  point  out  elsewhere 
upon  different  circumstances,  it  may  therefore  vary  considerably 
also  in  continuously  in-breeding  marriages.  It  is  further  possi- 
ble in  such  marriages  for  the  unfruitfulness  to  commence  in 
later  generations  only,  a  view  not  taken  into  consideration  by 
all  authors.  (Compare  the  statements  on  the  subject  by  Boudin 
and  Bailey.}  Finally  the  name  may  soon  disappear,  though 
the  number  of  descendants  of  such  consanguineous  marriages 
is  generally  large  or  of  normal  proportions,  because  the  male 
members  of  the  family  die  off  and  the  blood  is  maintained  in 
the  female  line  only.  Evidence  in  favour  of  this  last  supposition 
will  be  found  in  the  works  of  Lorenz  and  Peipers. 

As  to   the   vitality  of  the   newly-born   children   and   the 


ioo  HEALTH,  DISEASE,  MARRIAGE 

descendants  of  consanguineous  marriages  we  know  absolutely 
nothing  definite. 

As  results  of  marriage  between  blood-relations  have  also 
been  observed  all  kinds  of  degenerative  phenomena,  especially 
blindness,  deaf-mutism,  idiocy,  insanity,  polydactylism  and 
other  malformations. 

Generally-hereditary  eye-diseases  in  the  narrower  sense  of 
the  word,  or  laterally-hereditary  are:  Myopia  (or  at  least  a 
predisposition  to  it),  astigmatism,  irideremia,  coloboma  of  the 
iris,  coloboma  of  the  choroid,  ectopia  of  the  lens,  lamellar 
cataract,  retinitis  pigmentosa,  amaurotic  family  idiocy  (Sachs), 
hereditary  optic  neuritis  (Leber),  glaucoma,  congenital  nycta- 
lopia (Cutler),  colour-blindness,  microphthalmus. 

To  this  list  of  eye-diseases  ought  to  be  added  those  which 
may  with  some  justification  be  attributed  to  consanguinity. 
Their  number  is,  if  we  wish  to  rely  upon  fairly  ascertained  con- 
ditions, only  small.  Stilling  and  Laqueur  are  likewise  inclined  to 
impute  to  consanguinity  considerable  responsibility  for  cases  of 
very  severe  myopia.  Amaurotic  family  idiocy  attacks  accord- 
ing to  Sachs  almost  exclusively  Jewish  families  only,  and  is 
therefore  perhaps  to  a  certain  extent  also  connected  with  our 
subject.  But  by  far  the  most  important  condition  from  our  point 
of  view  is  the  retinitis  pigmentosa.  Heredity  may  be  proved  in 
about  half  the  number  of  cases  of  this  affection  of  the  retina. 
A  direct  transmission  from  parents  to  children  is  generally  rare 
and  extends  as  a  rule  over  two  generations  only.  More  fre- 
quent is  the  collateral  heredity.  The  affection  of  the  retina  may 
be  complicated  with  idiocy,  partial  deafness,  deaf-mutism,  poly- 
dactylism. Sometimes  the  affections  last-mentioned  alternate 
with  atrophy  of  the  retina  in  the  same  family.  And  just  as  these 
complications  also  appear  as  a  consequence  of  consanguineous 
marriages,  so  a  quarter  or  even  a  third  of  the  individuals 
affected  with  retinitis  pigmentosa  are  said  to  be  descended  from 
parents  who  were  consanguineous  in  various  degrees.  But  as  we 
shall  see,  the  percentage  of  consanguineous  marriages  is  a  much 
smaller  one,  it  cannot  indeed  be  doubted  that  consanguinity 
strengthens  here  materially  the  effect  of  heredity.  Unfor- 
tunately the  material  existing  in  the  literature  of  the  subject 


CONSANGUINITY  IN  MARRIAGE 


101 


is  comparatively  unimportant.    Schmidt  gives  the   following 
computation : 


Origin                                                           Origin 

Leber    . 

66 

1  8        Bayer 

I9 

5 

Hocquard 

15 

4        Nolden 

14 

3 

Horing 

4 

i        Derigs 

27 

7 

Bader    . 

60 

1  6        Agres 

25 

24 

Pagenstect 

er 

9 

o        Davitsor 

ii 

i 

Mooren 

34 

9        Fano 

7 

i 

Webster 

22 

3        Doric 

6 

o 

Hutchinsoi 

i 

23 

8        Dentie 

10 

2 

Wider   . 

41 

14        Schmidt 

43 

6 

Siegheim 

73 

9                               513  Cases      131=25.5$ 

calculated  22%,  Hirschberg  25%,  Moren, 
v.  Wecker,  Jager  33%,  Liebreich  40%.  Magnus  found  in 
Breslau  to  every  10,000  inhabitants  8.4  blind  Christians, 
whereas  Jews  showed  in  the  same  proportion  1 1  cases  of  blind- 
ness. The  proportion  between  Jews  and  Christians  is  therefore 
0.31 :  0.58.  Magnus  found  in  Jewish  blind-asylums  17.6%  of 
all  cases  of  disease  in  the  form  of  retinitis  pigmentosa  or  retinal 
atrophy. 

Finally  cases  of  retinitis  pigmentosa  are  so  absolutely  rare 
that  this  disease  alone  is  hardly  sufficient  to  justify  the  great 
literary  allegation  against  consanguinity  in  marriage.  It  would 
hardly  suffice  to  prevent  about  i  %  of  all  marriages. 

Boudin,  the  most  zealous  advocate  of  the  injuriousness  of 
consanguineous  marriages,  also  considers  them  on  the  strength 
of  old  opinions  to  be  mainly  responsible  for  the  more  frequent 
congenital  form  of  deaf-mutism.  He  maintains  that  28.35% 
of  all  congenital  deaf-mutes  spring  from  consanguineous  parents. 
But  the  statements  of  the  different  authors  vary  widely  with 
regard  to  this  percentage.  Scherbel  and  Peipers  give  compre- 
hensive compilations  of  the  same.  The  numerical  difference  is 
calculated  at  3.9-30.8%  (Huth) .  The  promised  statistics  of 
the  German  Imperial  Board  of  Health  are  unfortunately  not  yet 
available.  Existing  statements  greatly  differing  from  each  other 
do  not  make  it  seem  very  probable  that  consanguineous  mar- 
riages are  the  most  important  cause  of  deaf-mutism.  I  should 
also  like  to  mention  that  in  different  countries  deaf-mutism  is 


102  HEALTH,  DISEASE,  MARRIAGE 

uncommonly  variable  in  frequency.  According  to  G.  Mayr,  there 
are  to  every  10,000  individuals  in  the  Argentine  Confederation 
42.45  male  and  43.29  female  deaf-mutes;  in  the  United  States 
of  North  America  4.57  male  and  3.82  female;  in  the  British 
Australian  settlements  only  3.88  male  and  1.77  female;  in 
Sweden  n.8  male  and  8.77  female.  But  these  figures  do  not 
correspond  in  the  least  to  the  different  frequency  of  consan- 
guineous marriages  in  these  different  countries.  It  is  therefore 
at  least  very  probable  that  the  causes  of  deaf-mutism  are  very 
complicated,  and  that  hygienic  and  social  conditions  also  play 
an  important  part  in  its  production.  As  a  further  proof  of  the 
injuriousness  of  consanguineous  marriages  Boudin  has  further 
cited  the  relative  frequency  of  deaf-mutism  among  such  classes 
and  nations  in  which  consanguineous  marriages  occur  more  fre- 
quently, that  is  especially  among  the  Jews,  and  also  among  the 
negroes.  Llebreich  has  calculated  in  the  Berlin  Asylum  for 
deaf-mutes,  27  deaf-mutes  to  every  10,000  Jews,  whereas  to 
10,000  Protestants  there  fall  6  deaf-mutes  and  to  10,000 
Catholics  3.1.  This  author  has  also  examined  the  eyes  of  241 
deaf-mutes  in  Dresden,  Breslau  and  Berlin  and  found  in  14 
retinitis  pigmentosa.  Of  these  there  were  8  individuals  belong- 
ing to  Jewish  families.  Whether  consanguineous  marriages  had 
anything  to  do  with  these  cases  Liebreich  could  not  ascertain. 
The  year-book  of  Prussian  statistics  gives  for  the  year  1871  in 
the  province  of  Prussia  17.8  deaf-mutes  per  10,000  inhabitants, 
in  Pomerania  12.0,  in  Posen  14.4;  whereas  in  the  whole  of 
Prussia  there  were  per  10,000  Catholics  10.27  deaf-mutes,  per 
10,000  Protestants  9.55,  per  10,000  Jews,  14.8.  In  1880  the 
proportion  was  for  Catholics  10.39,  for  Protestants  9.84",  and 
for  Jews  14.38.  (Notice  the  contrast  between  Liebreich' s  figures 
regarding  Catholics  and  these!) 

Boudin  has  also  drawn  into  the  argument  the  geographical 
distribution  of  deaf-mutism.  The  number  of  people  affected  is 
supposed  to  grow  with  the  seclusion  of  a  locality  and  its  con- 
sequent inaccessibility,  suggesting  of  course  that  consanguineous 
marriages  are  thereby  greatly  facilitated.  Thus  there  were 
reckoned  in  the  Seine  department  per  10,000  people  2  deaf- 
mutes,  in  Corsica  14,  in  the  high  Alps  23,  in  the  Canton 


CONSANGUINITY  IN  MARRIAGE  103 

Berne  28.  The  proportion  of  deaf-mutes  in  the  Austrian  high- 
lands amounts  in  Austria  above  the  Enns  16.21  per  10,000,  in 
Salzburg  27.81,  in  Styria  20.6,  in  Carinthia  49.45;  whereas 
the  proportion  for  the  whole  of  Cisleithania  is  only  9.6.  In  the 
districts  of  Zell  am  See  (Salzburg),  St.  Veith,  and  Wolfsberg 
(Carinthia),  the  proportion  exceeds  50!  No  one  can  accuse 
here  consanguinity  alone.  Apparently  goitre  and  cretinism  are 
also  important  factors,  though  it  must  be  admitted  that  these 
two  affections  have  also  been  spoken  of  in  connection  with  con- 
sanguinity. There  is  however  as  yet  no  justification  for  this. 
Peipers  found  recently  with  regard  to  the  Briihl  asylum  for. 
deaf-mutes  as  follows:  A  little  over  1.6%  of  the  marriages 
which  produce  deaf-mute  children  are  consanguineous;  2.3% 
of  the  deaf-mute  children  spring  from  consanguineous  mar- 
riages. With  regard  to  the  asylum  in  Essen:  Just  over  2.25^* 
of  the  marriages  which  produce  deaf-mute  children  are  consan- 
guineous; 3.8%  of  the  children  appear  to  be  of  consanguineous 
origin;  (for  Neuwied:  a  little  more  than  4.6%  of  the  marriages 
which  produce  deaf  and  dumb  children  are  consanguineous; 
6.1%  of  the  deaf  and  dumb  children  spring  from  consanguineous 
marriages  [small  material!]) . 

Deaf-mutism  is  consequently  by  no  means  such  an  indubi- 
table result  of  parental  consanguinity  as  retinitis  pigmentosa 
in  spite  of  all  statistical  endeavours.  But  if  the  frequent  occur- 
rence of  deaf-mutism  among  blood-relations  is  noticed  again 
and  again  though  possibly  in  association  with  other  different 
causes,  it  becomes  our  duty,  looking  at  the  matter  from  the 
important  practical  point  of  view,  to  oppose  as  a  rule  con- 
sanguineous marriages. 

Mental  degeneration  and  insanity  have  also  been  advanced 
as  decided  consequences  of  marriages  between  consanguineous 
men  and  women.  It  is  said  that  the  descendants  of  such  mar- 
riages exhibit  diminished  stimulativeness  and  vigourousness, 
weaker  impulsiveness  and  a  predominance  of  the  phlegmatic 
temperament,  a  decreased  resistibility  against  disturbances  of 
nutrition  and  causes  of  disease.  These  assertions  are  hardly 
suitable  for  criticism.  But  if  idiocy,  epilepsy  with  insanity  and 
even  paralysis  are  named  here,  statistics  ought  to  help  us  to 


104  HEALTH,  DISEASE,  MARRIAGE 

come  to  a  decision  if  there  are  undoubted  foundations  for  the 
statement,  but  this  can  hardly  be  said  to  be  the  case.  A  perti- 
nent psychiatric-statistical  contribution  has  been  recently  given 
us  by  Peipers;  it  considers  a  part  of  the  pathogenic  predis- 
positions and  diseases  coming  into  question,  and  is  highly  valu- 
able both  as  a  criticism  and  in  its  data.  I  myself  base  my 
observations  on  the  fuller  statistics  by  Mayet  mentioned  in  the 
subsequent  chapter. 

In  the  case  of  congenital  malformations  of  the  fingers, 
heredity  can,  as  is  well  known,  be  demonstrated  in  many  cases. 
It  is  however  possible  that  here  also  consanguinity  comes  into 
question  as  a  factor  aggravating  the  effect  of  heredity.  But 
neither  these  nor  other  congenital  malformations  drawn  into  the 
discussion  can  claim  any  greater  significance. 

Statistics. — The  numerical  method  on  a  large  scale  has 
hitherto  not  been  adopted  for  the  purpose  of  deciding  the  ques- 
tion as  to  the  injuriousness  of  consanguineous  marriages.  The 
older  statistical  attempts  are  on  account  of  the  smallness  of  the 
material  upon  which  they  are  based  and  on  account  of  the  man- 
ner in  which  their  conclusions  are  drawn  so  unreliable  that  there 
is  every  justification  for  taking  here  into  consideration  a  few 
compilations  by  Peipers  on  the  subject,  and  also  principally  the 
latest  statistics  on  consanguineous  marriage  namely  those  of 
P.  Mayet  who  has  tried  to  utilise  very  extensive  data  which 
have  never  been  requisitioned  hitherto.  Just  now  the  subject 
is  of  actual  importance,  seeing  that  some  little  time  ago  the 
Federation  of  German  Governments  have  decided  upon  a  cur- 
rent census  of  deaf-mutes  in  the  German  Empire  to  be  under- 
taken by  the  Imperial  Board  of  Health. 

Mayet  recognised  as  the  first  important  point  the  necessity 
of  obtaining  information  as  to  the  percentage  of  the  population 
springing  from  consanguineous  marriages.  He  thinks  he  can 
ascertain  indirectly  the  percentage  of  consanguineous  descend- 
ants by  ascertaining  first  the  number  of  marriages  between 
blood-relations.  The  number  of  these  marriages  is  at  present 
being  established  in  France,  Bavaria,  Prussia  and  Hungary.  It 
is  also  known  though  for  a  number  of  years  only,  with  regard 
to  Alsace-Lorraine,  Saxony  and  Italy.  Finally  there  exists  the 


CONSANGUINITY  IN  MARRIAGE 


105 


statistical  raw  material  to  establish  it  for  Brunswick,  Saxe- 
Meiningen,  Hesse,  Anhalt  and  Schaumburg-Lippe,  and  also  for 
Spain. 

The  Italian  Registrar-General  of  Statistics  has  his  doubts 
as  to  the  exactness  of  the  reports  issued  by  the  communal 
authorities,  because  marriages  between  cousins  do  not  require 
there  any  dispensation. 

The  respective  conditions  in  France  are  clearly  seen  from 
Tables  I  and  II. 

Taken  together  they  give  information  over  a  period  of 
43  years  with  regard  to  126,945  marriages  between  blood- 
relations,  but  it  is  certain  that  they  do  not  include  all  such 
marriages  which  have  taken  place  in  France.  The  increase  in 
the  proportion  during  the  decade  of  1861-1871  (Table  I.) 
may  be  due  to  a  Ministerial  ordinance  issued  at  that  time 
enjoining  most  careful  investigation  in  that  direction.  The 
steady  diminution  in  the  average  figures  (Table  II.)  may  con- 
sequently be  explained  in  a  similar  way,  that  the  regulation  in 
question  has  gradually  been  permitted  to  fall  into  desuetude. 
How  much  of  it  is  due  to  a  possible  recognition  of  the  injuri- 
ousness  of  consanguineous  marriages  it  is  difficult  to  say. 


TABLE  I. 

(Source:  Stieder,  Statist.  Mittheil.  Elsass-Lothringen,  Part  12.) 
CONSANGUINEOUS  MARRIAGES  IN  FRANCE  FROM  1853-1871: 


Period 

Marriages 
Altogether 

Including  Consan- 
guineous Marriages 

Per  1,000  Marriages 
there  were  Consan- 
guineous Marriages 

1853—55 

834,840 

7,804 

9-34 

1856  —  60 

1,474,320 

14,735 

9-99 

1861—65 

1,508,914 

17,937 

11.89 

1866  —  71 

1,663,239 

20,896 

12.56 

io6  HEALTH,  DISEASE,  MARRIAGE 

TABLE  II. 

(Source:  Statistique  de  la  France,  Annees  1875-1898.) 


Years, 
Quinquennial 
Averages, 
Total  Sum, 
Total 
Average 

Marriages 

Per 

Classc 

looo  Marriages  of  all 
is  there  were  Consan- 
meous  Marriages 

Of  all 
Classes 

Between  Blood  Relations 

g 

Of  all 
Classes 

Between 

Of  all 
Classes 

Between 

_a 
°3 

o 
O 

-a 
a 

cfc 

wa 

a> 
a 
*5> 

3 
O 
O 

•o 
c"5 

p 

fea 

1875 
1876 

1877 
1878 
1879 

300,427 

291-  393 
278,034 
279,580 
282,776 

3483 
3313 
2962 
3165 
3047 

3242 
3063 
2692 
2936 
2841 

178 
179 
178 
182 
146 

63 

92 

47 

60 

1875/79   j 
average     ] 

286,442 

3194 

2955 

173 

66 

11,15 

10,32 

0,60 

0,23 

1880 
I88l 
1882 
1883 
1884 

279,046 
282,079 
281,060 
284,519 
289,555 

3240 
2925 
3052 
3139 
3M7 

3008 
2732 
2857 
2925 
2948 

175 
152 
160 
165 
159 

47 
41 
35 
49 

40 

1880/84  j 
average     | 

283,252 

3101 

2894 

162 

45 

io,95 

IO,22 

0,57 

0,16 

1885 
1886 
1887 
1888 
1889 

283,170 
283,208 
277,060 
276,848 
272,903 

3155 
3059 
3297 
2755 
2878 

2969 
2801 
2476 
2552 
2552 

149 
195 
178 
1  68 
231 

37 
63 
143 

35 
95 

1885/89     j 
average      ( 

278,638 

3029 

2770 

184 

75 

10,87 

9,94 

0,66 

0,87 

1890 
1891 
1892 

1893 
1894 

229,332 
285,458 
290,319 
287,294 
286,662 

2456 
2769 
3167 
2664 
2596 

2321 
2597 
2949 
2416 

2452 

101 

146 

142 
213 

i 

34 
26 
76 
35 
14 

1890/94     j 
average     / 

283,813 

2730 

2547 

183 

9,62 

8,97 

0,65 

1895 
1896 
1897 
1898 

282,915 
290,171 
291,462 
287,179 

2526 
2564 
2957 
2834 

2397 
2435 
2762 
2650 

129 
129 

195 

184 

1895/98     j 
average     | 

287,932 

2720 

2561 

159 

9,45 

8,45 

o,55 

In  the  24  years 

1875—98  to- 
gether 

average 

6,792,450 
283,852 

7I.IIO 

2965 

65,573 

2753 

5077 

212 

10,45 

9.70 

o,75 

CONSANGUINITY  IN  MARRIAGE 


107 


Table  III.  deals  with  Bavaria.  Here  also  the  average 
figures  become  less  every  5  years.  The  frequency  of  consan- 
guineous marriages  in  Bavaria  is  only  6/10  of  that  in  France. 

TABLE  III. 

MARRIAGES  BETWEEN  BLOOD-RELATIONS  IN  THE  KINGDOM  OF 
BAVARIA  FROM  1879  TO  1899. 


Marriages 

Per  1000  Marriages  of  all 

Between  Blood  Relations 

gineous  Marriages 

Years, 

Quinquennial 
Averages, 

Between 

Between 

Total  Sum, 

Total 
Average 

Classes 

Of  all 
Classes 

• 
_c 
"55 

•d 
»| 

<D  v 

*S 

o  3 
& 

Of  all 
Classes 

• 
_g 
'tn 
3 

•O 

in 

OT  o 

4)  <O 

ta 

«  3 
fe 

o 

2'<z 

<u-O 

O 

°fc 

<u-O 

O 

D 

*§ 

O 

t> 

*§ 

1879 

35,066 

330 

283 

34 

13 

1881 

35,538 

315 

266 

38 

II 

1882 

37,8oi 

3" 

271 

25 

15 

1883 

35,985 

322 

272 

3i 

19 

1884 

36,733 

321 

287 

29 

5 

Quinquennial  j 
Average        ) 

36,225 

320 

276 

3i 

13 

8,83 

7,62 

0,85 

0,36 

1885 

36,496 

3" 

273 

27 

ii 

1886 

37,324 

262 

231 

19 

12 

1887 

37,436 

242 

216 

16 

IO 

1888 

37,809 

245 

221 

I? 

7 

1889 

39-515 

259 

242 

ii 

6 

1885/89    J 

37,716 

264 

237 

El 

9 

7,OO 

6,28 

0,48 

O,24 

1890 

40,004 

271 

243 

22 

6 

1891 

41,400 

206 

196 

9 

I 

1892 

41,683 

165 

158 

7 

— 

I893 

41,605 

246 

213 

23 

IO 

1894 

42,623 

235 

205 

21 

9 

1890/94     j 
average     ( 

41,463 

225 

2O3 

17 

5 

5,43 

4,90 

O,4I 

0,12 

1895 

43,273 

262 

235 

21 

6 

1896 

45,258 

245 

217 

23 

5 

1897 

46,481 

249 

227 

16 

6 

1898 

48,464 

295 

269 

21 

5 

1899 

50,783 

203 

185 

14 

4 

1  895/99     j 
average      j 

46,852 

251 

227 

19 

5 

5,36 

4,84 

O,4I 

0,11 

The  20  years 

1879  —  99  to- 

811,277 

5295 

4710 

424 

161 

gether 

average 

40,564 

265 

236 

21 

8 

6,35 

5,82 

0,52 

0,19 

io8 


HEALTH,  DISEASE,  MARRIAGE 


Table  IV.  contains  the  figures  for  Prussia.  They  are  in 
striking  agreement  with  those  for  Bavaria.  Mayet  gives  also 
the  two  averages  for  the  longer  periods  taken  together. 

TABLE  IV. 

MARRIAGES  BETWEEN  BLOOD-RELATIONS  IN  THE  KINGDOM  OF 
PRUSSIA  FROM   1875  TO   1899. 

(Source:  Parts  of  "Prussian  Statistics"  which  deal  with  births, 

marriages,  etc.) 


Years, 
Quinquennial 
Averages, 
Total  Sum, 
Total 
Average 

Marriages 

Per 

1000  Marriages  of  all 
ss  there  were  Consan- 
neous  Marriages 

Of  all 
Classes 

Between  Blood  Relations 

g 

Of  all 
Classes 

Between 

Of  all 
Classes 

Between 

00 

_B 

3 
O 
O 

•d 
S. 

£• 

kti 

V  3 

c-d 

• 

o 
0 

•d 

§« 
»  o 

4)  V 
P 

fea 

oi  3 

1875 
1876 
1877 
1878 
1879 

230,841 
221,712 
210,337 

207,754 
206,752 

1342 
1993 
1847 
1711 

1413 
1227 

1773 
1695 
1522 

106 
96 
1  66 
122 
159 

38 
19 

54 
30 
30 

1875/79    i 
average     | 

215,479 

1690 

1526 

130 

34 

7,84 

7,08 

0,6O 

0,16 

1880 
1881 
1882 
1883 
1884 

208,456 
209,586 
217,239 
220,748 
225,939 

1685 
1660 
1622 
1702 
1685 

1519 
1490 
1470 
1528 
1536 

133 
144 

116 

148 

120 

33 
26 
36 
26 

29 

1880/84    1 
average     ( 

216  394 

1671 

1509 

132 

30 

7,72 

6,97 

0,61 

0,14 

1885 
1886 
1887 
1888    ' 
1889 

230,707 
231,588 
229,999 
233,421 
240,996 

1653 
1563 

1549 
1526 

1513 

1489 
1380 

H23 
1408 

1375 

137 
157 
III 
103 
1  10 

27 
26 

15 
15 

28 

1885/89      I 
average     / 

233,342 

1561 

1415 

124 

22 

6,69 

6,06 

o,53 

0,09 

1890 
1891 
1892 
1893 
1894 

244,657 
245,906 

245,447 
248,348 
250,960 

1345 
1383 
1442 

1365 
1402 

1238 
1249 
1282 
1262 
1293 

87 

114 

139 
85 

100 

2O 
20 
21 

18 
9 

1890/94     j 
average 

247,064 

1387 

1265 

105 

<7 

5,6i 

5,12 

0,42 

0,07 

CONSANGUINITY  IN  MARRIAGE 


109 


Marriages 

Per  looo  Marriages  of  all 

Between  Blood  Relations 

gineous  Marriages 

Years, 

Quinquennial 

Between 

Between 

Averages, 

Total  Sum, 

Ctt    alt 

Total 
Average 

Classes 

Of  all 

• 

•a 

9i 

t* 

Of  all 

• 

•o 

*a 

Classes 

01 

3 

™  0 

•§.<! 

Classes 

'3 

3 

*  o 

1)    V 

04 

O 

°  J5 

4>T3 

0 

a* 

«-O 

O 

P 

x< 

O 

D 

*« 

1895 

253,729 

I3bo 

1232 

109 

19 

1896 

264,822 

1376 

1263 

96 

17 

1897 

274,693 

1409 

1282 

103 

24 

1898 

280,344 

1227 

1126 

86 

15 

1899 

287,408 

1393 

1289 

86 

8 

1895/99     j 
average     j 

272,209 

1353 

1238 

96 

19 

4,97 

4,55 

0,35 

0,07 

The  25  years 

1875—99   to- 

5,922,439 

38,310 

34,764 

2933 

613 

gether 
average 

236,898 

1532 

1391 

116 

25 

6,47 

5,8? 

o,49 

0,11 

6.53 

6.47 
5.82 

5.87 

f  Marriages  between  uncle  and  niece. 
0.49) 


Marriages  between  blood-relations. 
h  Marriages  between 


cousins. 


Bavaria 

Prussia 

Bavaria 

Prussia 

Bavaria 

Prussia 

A  considerable  difference  is  seen  only  in  the  figures  (based 
on  small  numbers)  relating  to  marriages  between  nephew  and 
aunt.  They  are  for  Bavaria  0.19%  and  for  Prussia  0.11%. 

Table  V.  gives  the  Hungarian  figures  which  are  very 
similar. 

The  circumstance  that  the  figures  for  Prussia  and  Bavaria 
are  so  similar  appears  to  speak  for  their  accuracy,  but  Mayet 
thinks  they  are  certainly  too  low.  The  returns  of  the  particulars 
of  marriages  are  namely  often  filled  in  subsequently  from  the 
marriage-registers,  but  the  latter  have  no  column  with  respect 
to  the  consanguinity  of  the  parties  contracting  the  marriage. 
The  instructions  sent  out  in  Prussia  in  the  year  1874  as  to  the 
filling-in  of  the  marriage-returns  are  altogether  defective.  But 
the  numbers  of  the  present  Prussian  statistics  of  consanguineous 
marriages  supply  at  least  minimal  figures  which  are  useful  in 
different  ways. 


no  HEALTH,  DISEASE,  MARRIAGE 

TABLE  V. 

FOR  THE  YEAR  1900,  RELATING  TO  169,687  MARRIAGES  OF  ALL 

CLASSES. 

(Source:  Ungar.  statist.  Handbuch,  1900.) 


Marriages  Between 

First 
Cousins 

Uncle  and 
Niece 

Aunt  and 
Nephew 

In  Hungary,  in  one  year    .     . 
In  Croatia     

812 
109 

49 
10 

3 

I 

Together 

921 

59 

4 

that  is  % : 


In  Hungary 
In  Croatia, 

,  in  one  year  .     . 
in  one  year  .     .    . 

0-55 
0.52 

0.03 
0.05 

o.oo 
o.oo 

Together 

0.54 

0.03 

0.00 

In  England  it  seems  marriages  between  blood-relations  are 
much  more  frequent. 

In  any  event,  a  conclusion  as  to  the  percentage  of  consan- 
guineous descendants  in  proportion  to  the  whole  of  the  number 
of  children  born  in  wedlock  can  be  drawn  from  the  percentage 
of  consanguineous  marriages  in  proportion  to  the  number  of 
marriages  as  a  whole,  if,  firstly  consanguineous  and  crossed 
marriages  are  equally  fruitful,  and  secondly  if  the  newly-born 
infants  of  consanguineous  marriages  possess  the  same  vitality 
as  the  children  of  crossed  marriages.  As  far  as  I  am  concerned 
I  am  not  at  all  inclined  to  admit  the  parallelism  so  unrestrictedly 
as  Mayet  does.  The  number  of  births  depends  as  we  know  from 
experience  upon  a  variety  of  circumstances.  It  is  a  general 
natural  law  that  the  greater  the  danger  to  the  descendants  in 
the  struggle  for  existence  the  greater  the  propagative  faculty. 
Epidemics  f.  i.  tend  to  strengthen  it.  Thus  Moses  says: 
(Book  II,  Chap,  i.)  "But  the  more  they  afflicted  them  the 
more  they  multiplied  and  the  more  they  spread  abroad."  A 


CONSANGUINITY  IN  MARRIAGE  1 1 1 

natural  consequence  of  strict  in-breeding  is  rather  a  relaxation 
of  the  propagative  energy.  Jews  have  at  the  present  day  on  an 
average  fewer  children  than  other  nationalities  (presumably 
this  is  not  the  effect  of  in-breeding  only)  but  they  also  have 
a  smaller  infantile  mortality  and  a  longer  average  duration  of 
life.  With  a  small  number  of  consanguineous  marriages  calcu- 
lations with  respect  to  a  few  hundred  of  their  children  have 
repeatedly  been  made ;  but  they  showed  rather  greater  numbers. 
For  the  present  we  may  therefore  assume  at  least  hypothetically 
that  among  legitimately-born  children  the  offspring  of  blood- 
relations  occur  in  the  same  numerical  proportion  as  those  of 
non-consanguineous  parents.  Mayet  moreover  takes  the  relative 
number  of  consanguineous  marriages  in  proportion  to  1,000 
marriages  as  a  whole,  also  as  the  available  relative  number  for 
the  occurrence  of  all  sexual  unions,  consequently  for  the  entire 
number  of  consanguineous  descendants  among  the  population. 

In  Prussia  the  minimum  number  of  consanguineous  mar- 
riages is  6.5  per  mille.  If  we  take  for  Prussia  or  the  whole 
German  Empire  respectively  this  relative  figure  with  respect  to 
consanguineous  offspring,  it  would  mean  with  a  population  of 
56.3  millions  of  the  Empire  the  very  considerable  number 
of  365,950  descendants  of  consanguineous  marriages  living 
among  the  general  population. 

In  the  Prussian  lunatic  asylums  it  is  always  ascertained  in 
the  case  of  new  inmates  whether  and  in  what  degree  their 
parents  were  consanguineous.  In  the  published  returns  of  these 
statistics  "heredity"  is  entered  when  the  following  questions  are 
answered  in  the  affirmative  on  admission  into  the  asylum: 
Have  mental  or  nervous  disorders,  drunkenness,  suicide,  crime, 
striking  qualities  or  talents  been  present  in  father,  mother,  (I.)  ; 
grandfather,  grandmother,  uncle,  aunt,  (a)  on  the  father's  side, 
(b)  on  the  mother's  side,  (II.)  ;  brothers  or  sister,  (III.)  ?  The 
entry  "heredity"  means  therefore  in  these  statistics  not  only  a 
transmission  of  the  same  mental  disease,  but  much  more.  An 
abnormally  increased  nervous  life,  either  towards  excellence  or 
towards  decay,  and  that  not  only  in  one  of  the  absolutely 
nearest  ancestors,  is  sufficient  to  establish  "hereditary  predis- 
position." 


112 


HEALTH,  DISEASE,  MARRIAGE 


TABLE  VI. 


Heredity  is  proved  in 


Year 

i.  Simple  Insanity 

a.  Paralytic  Insanity 

M. 

F. 

M. 

P. 

Admissions 

Of  which 
heredity  is 
proved  in 

X  with 
heredity 

Admissions 

M 

IM  u  u 

o«& 

X  with 
heredity 

Admissions 

Cj  ^*— 

i  *O  s 
J3 

X  with 
heredity 

Admissions 

•g-2.s 

X  with 
heredity 

A.  On  the  number 


1884 

259<> 

814 

3020 

995 

844 

136 

2O5 

31 

1885 

2638 

139 

3167 

991 

963 

137 

244 

26 

1886 

2999 

912 

339° 

1044 

1085 

173 

237 

37 

1887 

3037 

866 

35io 

IIOI 

1  102 

174 

242 

27 

1888 

3<X)2 

801 

3559 

1149 

II4I 

I9I 

244 

51 

1889 

3165 

977 

3783 

1220 

1217 

237 

293 

50 

1890 

3438 

1068 

3974 

1309 

1315 

245 

309 

33 

1891 

3394 

1009 

3992 

1292 

1467 

229 

394 

48 

1892 

3407 

1034 

3039 

1349 

1363 

276 

386 

57 

1893 

3789 

1086 

4231 

1376 

1501 

280 

364 

65 

1894 

3798 

1231 

4429 

1445 

1488 

269 

461 

82 

1895 

3770 

1242 

4317 

1475 

1509 

328 

429 

93 

1896 

4098 

1236 

4463 

1437 

1646 

309 

479 

69 

1897 

4254 

1388 

4844 

1633 

1592 

309 

426 

77 

I4yrs.  ( 
to-  < 
gether  ( 

47,379 

14,503 

30,61 

54,718 

17,815 

32,56 

18,233 

3293 

1  8,06 

4703 

746 

15,86 

B.  On  the  number  of  Insane  admitted  whose  Parents  were  con- 


1884 

27 

18 

25 

ii 

3 

2 

— 

— 

1885 

24 

18 

22 

17 

3 

2 

— 

— 

1886 

17 

ii 

21 

15 

7 

3 

— 

— 

1887 

12 

5 

20 

ii 

3 

2 

— 

1888 

2O 

12 

19 

12 

3 

— 

— 

1889 

20 

14 

19 

II 

3 

2 

i 

1890 

23 

15 

16 

13 

8 

3 

i 

1891 

25 

18 

19 

IO 

5 

4 

i 

1892 

23 

16 

30 

2O 

8 

4 

— 

1893 

33 

22 

30 

19 

6 

I 

— 

— 

1894 

27 

18 

19 

13 

IO 

7 

— 

1895 

25 

21 

28 

19 

6 

i 

— 

1896 

27 

24 

29 

22 

8 

5 

i 

189 

29 

29 

25 

12 

— 

i4yrs.  j 
to-  < 
gether  ( 

338 

241 

71,30 

326 

218 

66,87 

85 

4i 

48,24 

IO 

4 

40,00 

TABLE  VII. 


(Compiled  by  Mayet  from  the 


For 

Hereditarily  predisposed  among 

Males 

Females        ||   Both  together 

I.  Simple  Insanity 
From  patients  of  all  classes    .     . 
From    patients    whose    parents 
were  consanguineous  .... 
2.  Paralytic  Insanity 
From  patients  of  all  classes    .     . 
From    patients    whose    parents 
were  consanguineous  .... 

30,61^  =  loo 

7I,3<*  =  233 

i8,o6jf  =  loo 

48,24*  =  267 

32,56^  =  100 
66,  87*  =  205 

I5,86g  =  100 

40,00*  =  252 

31,7*  =  ioo 
69,0$  =  218 

I7,6g  =  loo 

45-3*  =  257 

CONSANGUINITY  IN  MARRIAGE 


Prussian  lunatic  asylums 


3.  Insanity  with  Epilepsy 

4.  Imbecility  and  Idiocy 

Year 

M. 

F. 

M. 

F. 

Admissions 

Of  which 
heredity  is 
proved  in 

%  with 
heredity 

Admissions 

Of  which 
heredity  is 
proved  in 

%  with 
heredity 

Admissions 

Of  which 
heredity  is 
proved"  in 

H  with 
heredity 

Admissions 

•g".a 

*!" 

«-  £  ° 

8JE 

jfwith 
heredity 

of  Insane  admitted 


517 

92 

354 

72 

434 

92 

284 

67 

1884 

339 

60 

261 

62 

426 

in 

280 

83 

1885 

385 

75 

281 

70 

505 

123 

213 

75 

1886 

369 

66 

269 

63 

506 

118 

328 

65 

1887 

38i 

76 

338 

59 

523 

130 

387 

105 

1888 

390 

97 

3" 

74 

533 

163 

335 

93 

1889 

457 

109 

309 

82 

540 

179 

422 

in 

1890 

470 

106 

374 

98 

667 

186 

418 

109 

1891 

603 

133 

439 

128 

670 

175 

448 

118 

1892 

786 

176 

578 

126 

1066 

352 

698 

2OI 

I893 

834 

237 

667 

194 

1090 

336 

765 

228 

1894 

810 

262 

583 

178 

924 

308 

614 

199 

I895 

847 

267 

550 

173 

964 

292 

640 

215 

1896 

981 

301 

582 

168 

976 

286 

659 

193 

1897 

8170 

2057 

25,18 

5897 

1547 

26,23 

9824 

2851 

29,02 

6592 

1862 

28,25 

1  14  yrs. 
I  to- 
j  gether 

sanguineous  (as  Uncle  and  Niece,  Aunt  and  Nephew,  Cousins) 


8 

3 

i 

— 

I 

— 

5 

— 

1884 

— 

— 

2 

2 

4 

3 

4 

i 

1885 

I 

i 

— 

— 

ii 

3 

5 

i 

1886 

— 

— 

3 

I 

7 

5 

7 

3 

1887 

2 

— 

— 

— 

H 

6 

7 

i 

1888 

— 

— 

5 

3 

7 

3 

8 

i 

1889 

2 

I 

— 

— 

9 

6 

5 

4 

1890 

— 

— 

i 

i 

8 

5 

12 

7 

1891 

2 

i 

2 

2 

12 

5 

3 

2 

1892 

5 

4 

2 

2 

15 

10 

9 

3 

1893 

9 

5 

8 

5 

17 

8 

10 

3 

1894 

6 

2 

3 

i 

8 

3 

9 

5 

1895 

3 

3 

i 

i 

15 

4 

7 

3 

1896 

7 

— 

6 

4 

8 

3 

10 

4 

1897 

45 

20 

44)44 

34 

22 

64,71 

136 

64 

47,06 

101 

38 

37,62 

)  14  yrs. 

\  t0- 

)  gether 

preceding  table.)      Cases  with  proved  heredity. 


For 

Hereditarily  predisposed  among 

Males 

Females         ||   Both  together 

3.  Insanity  with  Epilepsy 

From  patients  of  all  classes    .     . 

25,18$  =  IOO 

26,23$  =  IOO 

25,6$  =  loo 

From    patients    whose    parents 

were  consanguineous  .... 

44,44$  =  176 

64,71$  =  247 

53,2$  =  208 

4.  Imbecility  and  Idiocy 

From  patients  of  all  classes    .     . 

29,02$  =  100 

28,25$  =  loo 

28,7$  =  loo 

From    patients    whose     parents 

were  consanguineous  .... 

47,06$  =  162 

37,62$  =  133 

43,0$  =  150 

114 


HEALTH,  DISEASE,  MARRIAGE 


TABLE  VIII.    Heredity  is  proved  in  Prussian  asylums  on  the 


Year 

i.  Simple  Insanity 

a.  Paralytic  Insanity 

M. 

F. 

M. 

F. 

« 

O 

f,f'S 

* 

<a 
O 

aSa 

%  with 
heredity 

Admissions 

If  > 
«2g 

o|& 

*  with 
heredity 

Admissions 

.c-aa 

s*8 

?-a  > 
O  <u  a 

X  with 

heredity 

Admiss 

ojjs. 

**,s 

Admiss 

.C 

C.  As 


1884 

25 

17 

22 

9 

3 

2 

— 

— 

1885 

22 

16 

18 

15 

3 

2 

— 

— 

1886 

13 

8 

18 

12 

5 

2 

— 

— 

1887 

12 

5 

18 

9 

3 

2 

i 

— 

1888 

18 

ii 

18 

ii 

3 

— 

— 

— 

1889 

17 

12 

18 

10 

2 

I 

I 

— 

1890 

22 

14 

16 

13 

8 

3 

— 

— 

1891 

24 

17 

15 

8 

4 

4 

I 

1892 

20 

13 

27 

18 

7 

3 

I 

1893 

27 

18 

27 

17 

6 

i 

— 

1894 

25 

16 

15 

10 

10 

7 

— 

I895 

21 

18 

26 

17 

6 

i 

— 

1896 

25 

22 

29 

22 

6 

3 

I 

I897 

31 

25 

26 

22 

12 

— 

14  yrs.  j 

to-  I 
gether) 

3O2 

212 

70,2 

293 

193 

65,9 

78 

36 

46,2 

9 

3 

33.3 

D.  As  Uncle 

1884 

2 

I 

3 

2 

— 

— 

— 

— 

1885 

2 

2 

4 

2 

— 

— 

— 

— 

1886 

4 

3 

3 

3 

2 

i 

— 

— 

1887 

— 

— 

2 

2 

— 

— 

— 

— 

1888 

2 

I 

I 

I 

— 

— 

— 

— 

1889 

3 

2 

I 

I 

I 

i 

I 

I 

1890 

i 

I 

— 

— 

— 

— 

— 

— 

1891 

i 

I 

4 

2 

I 

— 

— 

— 

1892 

3 

3 

3 

2 

I 

i 

— 

— 

1893 

6 

4 

3 

2 

— 

— 

— 

-  — 

1894 

2 

2 

3 

2 

— 

— 

— 

— 

1895 

4 

3 

i 

I 

— 

— 

— 

— 

1896 

2 

2 



— 

2 

2 

— 

— 

1897 

4 

4 

2 

I 

— 

— 

— 

— 

14  yrs.  1 

to-  > 
gether) 

36 

29 

80,6 

30 

22 

73,3 

7 

5 

71,4 

i 

i 

IOO 

E.  As  Nephew 

1884 

— 

— 

— 

— 

— 

— 

— 

— 

1885 

— 

— 

— 

— 

— 

— 

— 

— 

1886 

— 

— 

— 

— 

— 

— 

— 

— 

1887 

— 

— 

— 

— 

— 

— 

— 

— 

1888 

— 

— 

— 

— 

— 

— 

— 

— 

1889 

— 

— 

— 

— 

— 

— 

— 

— 

1890 

— 

— 

— 

— 

— 

— 

— 

— 

1891 

— 

— 

— 

— 

— 

— 

— 

— 

1892 

— 

— 

— 

— 

— 

— 

— 

— 

1893 

— 

— 

— 

— 

— 

— 

— 

— 

1894 

— 

— 

I 

I 

— 

— 

— 

— 

1895 

— 

— 

I 

I 

— 

— 

— 

— 

1896 

— 

— 

— 

— 

— 

— 

— 

— 

1897 

— 

— 

I 

I 

— 

— 

— 

— 

I4£H 

•J 

3 

IOO 

gether 

9 

CONSANGUINITY  IN  MARRIAGE 


admission  of  those  insane  whose  parents  were  consanguineous. 


3.  Insanity  with  Epilepsy 

4.  Imbecility  and  Idiocy 

Year 

M. 

F. 

M. 

F. 

Admissions 

A-'"  G 
O  ^'" 
"5  *JT) 

^> 

*.£8 

OjSa 

%  with 
heredity 

Admissions 

Of  which 
heredity  is 
proved  in 

<  with 
heredity 

Admissions 

•g-2.s 

%  with 
heredity 

Admissions 

*.3a 

2.£g 

u.|o 

OjgR 

j^  with 
heredity 

Cousins 


5 

i 

i 

i 

— 

i 

— 

5 

— 

1884 

— 

— 

— 

2 

2 

4 

3 

3 

I 

1885 

— 

— 

— 

— 

— 

8 

2 

4 

I 

1886 

— 

— 

— 

2 

I 

7 

5 

7 

3 

1887 

2 

— 

— 

— 

— 

12 

4 

5 

i 

1888 

— 

— 

— 

4 

2 

6 

3 

7 

i 

1889 

2 

i 

i 

— 



8 

5 

4 

3 

1890 

— 

— 

— 

i 

I 

8 

5 

10 

6 

1891 

2 

i 

i 

2 

2 

12 

5 

3 

2 

1892 

5 

4 

4 

I 

I 

13 

9 

9 

3 

1893 

8 

5 

5 

8 

5 

17 

8 

8 

3 

1894 

6 

2 

2 

3 

i 

8 

3 

8 

4 

1895 

2 

2 

2 

i 

i 

12 

3 

5 

2 

1896 

7 

"•" 

— 

6 

4 

7 

2 

10 

4 

1897 

39 

16 

4I,O 

31 

2O 

64,5 

123 

57 

46,3 

88 

34 

38,6 

['Ye*' 
)  gether 

and  Niece 

3 

2 

— 

— 

— 

— 

— 

— 

1884 

— 

— 

— 

— 

— 

— 

i 

— 

1885 

I 

I 

— 

— 

3 

2 

i 

— 

1886 

— 

— 

i 

— 

— 

— 

— 

— 

1887 

— 

— 

— 

— 

2 

I 

2 

— 

1888 

— 

— 

i 

I 

I 

— 

I 

— 

1889 

~~ 

—• 

— 

— 

I 

I 

I 

i 

1890 

~~ 

~~ 

— 

•*•• 

— 

— 

2 

i 

1891 

— 

~~ 

— 

•"•  ~ 

— 

— 

— 

— 

1892 

— 

— 

i 

I 

2 

I 

— 

— 

1893 

i 

— 

— 

— 

— 

— 

2 

i 

1894 

— 

~~ 

— 

— 

— 

— 

I 

— 

1895 

i 

I 

— 

— 

3 

I 

2 

— 

1896 

i 

I 

— 

— 

1897 

6 

4 

66,7  1|  13 

2 

66,7 

13 

7 

53,8  ||  13 

3 

23,1 

)  i4vrs. 
>  to- 
|  gether 

and  Aunt 

— 

— 

— 

— 

— 

— 

— 

— 

1884 

— 

— 

— 

— 

— 

— 

— 

— 

1885 

— 

— 

— 

— 

— 

— 

— 

— 

1886 

— 

— 

— 

— 

— 

— 

— 

— 

1887 

— 

— 

— 

— 

— 

— 

— 

— 

1888 

— 

— 

— 

— 

— 

— 

— 

— 

1889 

— 

— 

— 

— 

— 

— 

— 

— 

1890 

— 

— 

— 

— 

— 

— 

— 

— 

1891 

— 

— 

— 

— 

— 

— 

— 

— 

1892 

— 

— 

— 

— 

— 

— 

— 

— 

1893 

— 

— 

— 

— 

— 

— 

— 

— 

1894 

— 

— 

— 

— 

— 

— 

— 

— 

1895 

— 

— 

— 

— 

— 

— 

— 

— 

1896 

— 

— 

— 

— 

— 

— 

1897 

1  14  yrs. 
V  to- 

\  gether 

n6  HEALTH,  DISEASE,  MARRIAGE 

Let  us  examine  now  Mayers  table  with  regard  to  this 
heredity  (Table  VI.).  The  items  in  the  sum-total  of  the 
Part  A  refer  to : 

Male  Female 

Patients.  Patients. 

Simple  insanity 47,000  55,000 

Paralytic  insanity   ....      18,000  5,000 

Insanity  with  epilepsy     .     .       8,000  6,000 

Imbecility,  Idiocy  ....      10,000  7,000 

A  fairly  large  material.  Near  each  column  of  admissions  there 
is  a  column  giving  the  percentage  of  hereditary  cases. 

The  table  gives  in  a  satisfactory  manner  the  items  of  those 
mental  diseases  where  the  parents  were  consanguineous.  The 
information  on  the  point  refers  to  a  fairly  considerable 
material : 

Male  Female 

Patients.  Patients. 

Simple  insanity 338  326 

Paralytic  insanity  ....  85  10 

Insanity  with  epilepsy ...  45  34 

Imbecility,  Idiocy  ....  136  101 

Together  in  mentally  de- 
ranged descendants  of  con- 
sanguineous marriages     .     .  604  471 
We  can  see  from  this  by  comparing  the  percentages  on 
the  same  side  that  the  number  of  those  who  are  hereditarily 
predisposed  is  in  the  insane  whose  parents  were  consanguineous 
much  larger,  as  a  rule  more  than  twice  as  large,  than  in  those 
who    were    descended    from    non-consanguineous    marriages. 
Table  VII.  gives  a  clearer  view  of  this  conclusion.   The  com- 
parison between  the  two  relative  figures  is  made  easier  by  taking 
the  relative  figure  for  patients  as  a  whole  as  100.   We  find  in 
the  case  of  consanguineous  descendants  218,  257,  208,   150, 
hereditarily  predisposed,  against  100  patients  of  all  classes. 

Mayet  explains,  as  I  believe,  these  figures  quite  correctly; 
the  mental  diseases  arise  often  on  the  basis  of  unfavourable 
family-predispositions.  If  the  same  family-predisposition  is 
present  in  both  consanguineous  parents  the  effects  of  the  heredity 
are  considerably  increased.  In  simple  insanity,  paralytic  insanity, 


CONSANGUINITY  IN  MARRIAGE 


117 


and  insanity  associated  with  epilepsy,  heredity  plays  in  the  case 
of  consanguineous  descendants  a  part  which  has  the  effect  of 
more  than  doubling  the  number  of  cases.  As  regards  imbecility 
and  idiocy,  heredity  seems  to  play  a  less  important  part. 

Table  VIII.  gives  the  data  separately  with  regard  to  the 
degree  of  consanguinity.     (Under  C.  D.  E.) 

TABLE  IX. 

(Compiled  by  Mayet  from  Tables  VI.  and  VIII.) 

Cases  with  proved  heredity 


Hereditarily  predisposed  among 

Males 

Females 

Both  together 

i.  Simple  Insanity 

From  patients  of  all  classes     . 

30,61  % 

=   IOO 

32,56#  = 

IOO 

31,7  % 

=  IOO 

From  patients  whose  parents 

were  cousins  

70,2    ,, 

=  230 

6<;,Q   ,,  = 

2O2 

68,1  ,, 

=  2IS 

From  patients  whose  parents 

~  J^r 

v  ji  ^   »  i 

j 

were  uncle  and  niece  .     . 

80,6    ,, 

=  263 

73,3    ..  = 

225 

77,3,, 

=  244 

2.  Paralytic  Insanity 

From  patients  of  all  classes     . 

18,06$ 

=   IOO 

15,86$  = 

IOO 

17,6$ 

=   IOO 

From  patients  whose  parents 

were  cousins  

46,2    ,, 

=  256 

W.1*       ,.    = 

2IO 

44,8  ,, 

=  255 

From  patients  whose  parents 

*JJ*  J       >  1 

were  uncle  and  niece  .     .     . 

71,4   ,, 

=  395 

100      ,,  = 

631 

75,0,, 

=  426 

3.  Insanity  with  Epilepsy 

From  patients  of  all  classes     . 

25,18$ 

=   IOO 

26,23$  = 

IOO 

25,6$ 

=  IOO 

From  patients  whose  parents 

were  cousins  

4i.o   ,, 

=  163 

64,5    ,,  = 

246 

50,0,, 

=  195 

From  patients  whose  parents 

were  uncle  and  niece  .     .     . 

66,7   ,. 

=  265 

66,7   ,,  = 

254 

66,7  ,, 

=  261 

4.  Imbecility  and  Idiocy 

From  patients  of  all  classes     . 

29,02$ 

=   IOO 

28,25$  = 

IOO 

28,7$ 

=   IOO 

From  patients  whose  parents 

were  cousins  

46,3    ,, 

=  1  60 

38,6   ,,  = 

137 

4^.1  .. 

=  150 

From  patients  whose  parents 

*  J  1 

*TJ)  "11 

were  uncle  and  niece  .     .     . 

53,8    „ 

=  185 

23,1    ,,  = 

82 

38,5  ,, 

=  134 

Table  IX.  facilitates  the  comparison  in  certain  other  direc- 
tions. According  to  this  table  it  seems  that  in  simple  insanity, 
in  paralytic  insanity,  and  in  insanity  with  epilepsy,  hereditary 
predisposition  is  demonstrable  to  a  greater  extent  in  the  off- 
spring of  uncle  and  niece  than  in  that  of  cousins;  it  is  there- 
fore more  pronounced  where  the  relationship  is  nearer. 

It  is  different  with  imbecility  and  idiocy,  just  as  we  should 


n8 


HEALTH,  DISEASE,  MARRIAGE 


expect,  considering  that  in  these  affections  hereditary  predis- 
position is  altogether  rare. 

Subdivision  E.  of  Table  VIII.  which  refers  to  the  descend- 
ants of  marriages  between  nephew  and  aunt  shows  in  the  group 
of  Table  IX.  hardly  any  cases  of  insanity.  That  such  unions 
are  in  any  way  protective  against  insanity  is  far  less  likely  than 
that  they  are  (on  account  of  the  advanced  age  of  most  aunts) 
much  less  fruitful. 

Table  X.  prepared  by  Mayet  gives  the  proportion  of 
descendants  of  consanguineous  marriages  to  the  entire  number 
of  sufferers  from  the  forms  of  insanity  already  mentioned,  and 
from  idiocy. 

TABLE  X. 

PROPORTIONATE  NUMBER  OF  PATIENTS  WHOSE  PARENTS  ARE 

CONSANGUINEOUS  TO  THE  ENTIRE  NUMBER  OF  PATIENTS 

OF  EACH  FORM  OF  DISEASE: 

(Compiled  from  Table  VI.) 


i.  Simple  Insanity 

2.  Paralytic  Insanity 

3.  Insanity  with 
Epilepsy 

4.  Imbecility 
and  Idiocy 

• 

Of  whom 

01 

Of  whom 

• 

Of  whom 

01 

Of  whom 

with  1  without 

e 

with  I  without 

with  |  without 

V 

with  !  without 

1 

proved 
heredity 

• 

a, 

proved 
heredity 

rt 

IX 

proved 
heredity 

& 

proved 
heredity 

A.  Insane  of  all  Classes 


M. 
F. 

47379 

54718 

M503 
17815 

J  18233 
4703 

3293 
746 

8170 
5897 

2057 
1547 

9*824 
6592 

2851 
1862 

M.&  F. 
together 

102097 

32318 

22936 

4039 

14067 

3604 

10463 

16416 

4713 

11703 

B.  Insane  whose  Parents  were  consanguineous 


M. 
F. 

338 
326 

241 

218 

85 

10 

41 
4 

45 
34 

20 

22 

136 

IOI 

64 

38 

M.  &  F. 
together 

664 

459 

205 

95 

45 

50 

79 

42 

37 

237 

IO2 

135 

The  Insane  whose  Parents  were  consanguineous  (B),  average  per  1000 
insane  persons  (A) : 


M.&  F. 
togi 


VJ 

etherf 


14,2       3,0 


4,1 


II, I    I    2,9     I    5,6        11,7   I    3,5    I  14,4  I   21,6  I   11,5 


Whilst  of  looo  inhabitants  of  Prussia  at  least  6.47  descendants  spring  from 
consanguineous  marriages 


CONSANGUINITY  IN  MARRIAGE  1 19 

From  these  figures  it  would  appear  that  the  proportion  of 
consanguineous  descendants  suffering  from  the  respective  forms 
of  insanity  to  the  total  number  of  individuals  who  do  not  seem 
to  be  hereditarily  predisposed  in  the  sense  explained  above,  is 
smaller  than  their  proportion  to  the  entire  population.  Mayet 
expects  according  to  the  above  given  minimum  figure  of  6.5 
descendants  from  consanguineous  marriages  per  1,000  of  popu- 
lation to  find  also  6.5  per  mille  of  patients  of  this  class  in  pro- 
portion to  the  whole  number  of  patients  of  each  class,  but 
instead  of  6.5  he  gives  above :  of  simple  insane  only  3.0,  of  par- 
alytics only  2.9,  and  of  epileptics  only  3.5.  On  the  other  hand 
idiocy  stands  here  differently.  The  proportion  of  6.5  is 
exceeded  and  becomes  instead  1 1.5. 

Table  XI.  serves  for  the  special  study  of  the  conditions 
referring  to  the  children  of  cousins  and  to  those  of  uncle  and 
niece. 

This  table  shows  in  both  kinds  of  marriages  the  same  results 
where  there  is  no  gross  hereditary  predisposition  to  the  affec- 
tions mentioned;  as  to  the  three  forms  of  insanity  the  children 
are  half  as  frequently  insane  as  the  rest  of  the  population.  As 
regards  idiocy  the  conditions  are  again  of  a  totally  opposite 
character.  Here  the  "hereditarily  non-predisposed"  progeny  of 
married  cousins  are  relatively  almost  doubly,  and  those  of  uncle 
and  niece  almost  trebly  so  much  affected  as  the  general  popu- 
lation. 

Mayet  has  developed  this  latter  part  of  his  statistical  com- 
putation for  the  purpose  of  establishing  how  consanguinity  acts 
per  se,  that  is  exclusively  by  the  absence  of  outside  blood,  and 
quite  apart  from  the  aggravation  of  the  effect  of  heredity.  He 
thinks  he  can  draw  the  conclusion  that  in  idiocy  the  disease  is 
produced  by  consanguinity  as  such,  whereas  in  the  other  three 
forms  of  insanity  consanguinity  appears  to  be  rather  an  advan- 
tage in  the  case  of  "hereditarily  non-predisposed"  persons. 

Personally  I  can  admit  with  absolute  certainty  only  that 
much,  that  in  idiots  also,  if  in  addition  to  consanguinity  the 
well-known  stigmas  of  hereditary  predisposition  are  also  mani- 
festly present,  the  effect  is  a  vastly  greater  one.  I  should  further 
conclude  that  descent  from  consanguineous  parents  does  not 


120  HEALTH,  DISEASE,  MARRIAGE 

TABLE  XL 

PROPORTIONATE  NUMBER  OF  PATIENTS  WHOSE  PARENTS  WERE 

RELATED  TO  EACH  OTHER  AS  COUSINS  OR  AS  UNCLE 

AND  NIECE,  TO  THE   ENTIRE   NUMBER  OF 

PATIENTS  OF  EACH  FORM  OF  DISEASE. 

Compiled  from  Tables  VI.  and  VIII. 


i.  Simple  Insanity 

2.  Paralytic  Insanity 

3.  Insanity  with 
Epilepsy 

4.  Imbecility 
and  Idiocy 

«, 

Of  whom 

ai 

Of  whom 

U) 

Of  whom 

• 

Of  whom 

with  1  without 

4) 

with  I  without 

V 

with  |  without 

0) 

with  |  without 

1 

proved 
heredity 

« 

(X, 

proved 
heredity 

cu 

proved 
heredity 

a 

£ 

proved 
heredity 

A.  Insane  of  all  Classes 


M. 
F. 

47379 
547i8 

14503 
17815 

18233 
4703 

3293 

746 

8170 
5897 

2057 
1547 

9824 
6592 

2851 
1862 

M.  &  F. 
together 

102097 

32318 

69779 

22936 

4039 

18897 

14067 

3604 

10463 

16416 

4713 

II703 

C.  Insane  whose  Parents  were  related  as  Cousins. 


M. 
F. 

302 
293 

212 

193 

78 
9 

36 
3 

39 
31 

16 

20 

123 

88 

57 
54 

M.&  F. 
together 

595 

405 

I9O 

87 

39 

48 

70 

36 

34 

211 

IOI 

1  20 

The  insane  whose  Parents  were  related  as  Cousins  (C),  average  per  1000 

insane  persons  (A) : 
M.  &F.I    5,82!  12,5    I   2,70  I  3,80  I  9,66   I   2,54  I  4.98   I  9,98   I   3,25  I  12,85  I  19*13  I  10,26 

together!      '  |  I 

Whilst  of  looo  inhabitants  of  Prussia  at  least  5.87  descendants  spring  from 
marriages  between  cousins. 

D.  Insane  whose  Parents  were  related  as  Uncle  and  Niece. 


M. 

F. 

36 
30 

29 
22 

7 

I 

5 

I 

6 
3 

4 
2 

13 
13 

7 
3 

M.  &  F. 
together 

66 

51 

15 

8 

6 

2 

9 

6 

3 

26 

10 

16 

The  insane  whose  Parents  were  related  as  Uncle  and  Niece  (D),  average 
per  1000  insane  persons  (A) : 

M.  &F.I  0,64  I    1,58  I   0,22  I  0,35  I    1,48      o.n  I  0,64  I    1,67  I   0,29  I   1,58  I   2,12  I    1,37 
together! 

Whilst  of  looo  inhabitants  of  Prussia  at  least  0.49  descendants  spring  from 
marriages  between  Uncle  ana  Niece. 

Taking  above  under  C,  5.87  =  100,  the  relative  figures  are  under  C  = 

M.&Fj     99     I     213  I     46     I     65     I     165  I     43     I     85     I     170  I     55     I     219  I     329 
together!  I  I 

Taking  above  under  D,  0.49  =  100,  the  relative  figures  are  under  D  = 
M.  &J.\     131  I     322  I     45     I     70     I     302  I     22     I     131        341  I     59    I    322  I     433 

toertnrrl  I I 


175 


280 


CONSANGUINITY  IN  MARRIAGE  1 2 1 

per  se  predispose  to  insanity.  But  on  the  other  hand  I  think  it 
would  be  going  too  far  to  admit  like  Mayet  a  favourable  influ- 
ence with  regard  to  a  large  number  of  diseases.  That  idiocy 
may  become  manifest  in  the  descendants  of  consanguineous  mar- 
riages even  where  the  gross  (physical  but  especially  psychical) 
symptoms  of  hereditary  predisposition  are  absent,!  can  easily 
explain  by  the  law  of  heredity  laid  down  above,  namely,  that 
two  similar  predispositions  which  on  account  of  their  slight 
intensity  are  not  recognisable  in  the  parents  individually,  com- 
bine in  the  offspring  and  acquire  by  this  combination  such  an 
energy  that  they  appear  as  a  decided  characteristic.  For  this 
reason  I  have  already  at  the  commencement  of  my  remarks 
taken  into  consideration  the  aggravating  influence  of  consan- 
guinity upon  the  effect  of  heredity. 

Of  great  value  is  Mayet's  arithmetical  proof  that  of  16,416 
idiots  admitted  in  Prussian  asylums  only  237  were  descendants 
of  consanguineous  marriages.  Even  if  we  add  to  this  number 
those  idiots  who  are  maintained  in  their  parents'  homes,  the 
proportion  is  not  such  as  to  justify  a  serious  view  of  the  injuri- 
ousness  of  consanguineous  marriages.  There  are  probably  about 
200,000  consanguineous  descendants  among  the  inhabitants  of 
Prussia. 

In  all  likelihood  the  conditions  as  regards  congenital 
deaf-mutism  and  retinitis  pigmentosa  are  similar  to  those 
regarding  idiocy.  It  was  also  Mayet  who  has  furnished  statis- 
tical proofs  in  favour  of  this  opinion  with  respect  to  deaf- 
mutism.  L.  Hirsch  has  found  the  percentage  of  consanguineous 
marriages  undoubtedly  higher  among  the  congenitally-blind 
than  among  the  other  blind.  Of  340  congenitally-blind,  16  that 
is  5%  were  descended  from  consanguineous  marriages,  of  50 
blind  persons  with  retinitis  pigmentosa  9,  that  is  18%.  This 
author  maintains  that  it  is  quite  clear  that  this  percentage  of 
consanguineous  marriages  exceeds  by  far  that  among  the  non- 
blind  population.  Many  authors,  f.  i.  Leber  have  in  the  case 
of  retinitis  pigmentosa  found  even  a  higher  percentage  of  con- 
sanguineous parents  than  1 8  % .  ( See  Chapter  XV. ) 

Practical  conclusions. — The  foregoing  facts  and 
remarks  do  not  therefore  contain  anything  which  compels  us 


122  HEALTH,  DISEASE,  MARRIAGE 

to  see  in  the  results  of  consanguineous  marriages  more  than  an 
aggravation  of  the  effects  of  heredity  through  the  consanguinity. 
Jt  has  not  been  possible  to  establish  without  doubt  that  the 
absence  of  outside-blood  is  alone  responsible  for  the  degenera- 
tion in  the  offspring.  Even  the  optimum  of  in-and-in-breeding, 
or  its  latitude,  we  can  estimate  in  man  mainly  by  the  aid 
of  ethnographical  and  statistical  calculations  in  association  with 
the  laws  of  heredity;  its  definite  determination  is  one  of  the 
problems  of  the  future. 

The  practical  aim  of  anti-consanguinists  is  strict  legislation 
against  consanguineous  marriages,  that  of  the  consanguinists 
the  abolition  of  the  existing  prohibitions  (see  above).  If 
scientific  investigation  of  the  consequences  of  in-breeding  is  to 
influence  public  opinion  one  way  or  the  other  without  bias  or 
special  motives,  it  is  necessary  to  find  for  it  a  safe  and  broad 
foundation.  For  the  present  however  we  must  say :  Non  liquet. 

For  the  practitioner  on  the  other  hand  it  is  much  easier  to 
arrive  at  a  decision.  As  far  as  the  problematical  optimum  of 
consanguineous  marriages  with  regard  to  the  inheritance  of 
definite  moral  qualities,  etc.  is  concerned  he  will  prefer  to  leave 
it  alone.  But  generally  speaking  it  will  be  his  duty  to  dissuade 
from  the  contraction  of  marriages  by  blood-relations.  He  will 
depart  from  this  principle  on  very  rare  occasions  only,  even  if 
the  relatives  intending  to  marry  each  other  appear  to  be  in  a 
general  sense  absolutely  free  from  any  hereditary  predisposi- 
tion. For  according  to  the  laws  of  heredity  the  possibility  is 
not  precluded,  as  I  have  already  said  several  times,  that  two 
similar  predispositions  which  on  account  of  their  slight  intensity 
were  not  recognisable  in  the  parents  individually  may  combine 
in  the  offspring  and  become  so  pronounced  as  to  assume  a  definite 
pathological  character;  and  this  is.  moreover  especially  likely  to 
be  the  case  in  consanguineous  marriages. 

But  the  practitioner  will  also  do  well  to  oppose  marriages 
between  people  belonging  to  very  distant  races,  as  f.  i.  between 
Whites  and  Negroes.  (See  p.  27  in  Prof.  Gruber's  article.) 


CONSANGUINITY  IN  MARRIAGE  123 

Literature. 

A.  Dittrich:     Die  Bedeutung  der  Vererbung.    Tubingen  1903. 

Ribbert:    Ueber  Vererbung.    Marburg  1902. 

Ch.  Darwin:    On  the  origin  of  species.    1859,  deutsch  von  Bronn    (1863)  ; 

Variation  of  animals  and  plants  under  domestication,   1867. 
Schcnk:     Handbuch  der  Botanik.     I.  Bd. 
Reibmayr:    Inzucht    und    Vermischung   beim    Menschen.     Leipzig-Wien 

1897- 

Ribot:     L'heredite,  1873   (deutsch  von  Kurella). 

Scherbel:    Ueber  Ehen  zwischen  Blutsverwandten.    2.  Aufl.    Berlin  1896. 
Schiller-Tits:    Folgen,   Bedeutung  u.   Wesen  d.  Blutsverwandtschaft.    3. 

Aufl.  Leipz.   1892.     (Beide  letztgenannten,  sehr  lesenswerten  Werke 

enthalten  die  sorgfaltig  gesammelte  Literatur  fast  des  ganzen  Gegen- 

standes). 

O.  Lor  ens:     Lehrbuch  der  Genealogie.     Berlin  1898. 
Voisin:     fitude  sur  le  mariage  entre  consanguins  dans  la  commune  de 

Batz  (Ann.  d'hygiene  publ.  et  medecine  legale  II.  Ser.  t.  XXIII.  260). 

Paris  1865. 
Peipers:    Consanguinitat  in  der  Ehe.    Zeitschr.  fur  Psychiatric.    58.  Bd. 

S.  793  (1901). 
P.  Mayet:     Verwandtenehe  und  Statistik.      Jahrb.  der  internat.    Vereini- 

gung  fur  vergl.  Rechtswissenschaft  und  Volkswirtschaftslehie.    VI. 

u.  VIII.  Bd.  Sep.-Abdr. 


Climate,  Race   and   Nationality  in  Relation 
to   Marriage 


CLIMATE,    RACE    AND    NATIONALITY    IN 
RELATION    TO   MARRIAGE 

By  W.  Havelburg,  M.D.  (Berlin) 


PART  I 

Definition  of  acclimatisation. — By  acclimatisation 
in  general  we  understand  the  accommodation  of  any  living  being 
to  all  the  imaginable  influences  of  a  locality  foreign  to  it  or  to 
its  nearest  ascendants,  and  where  the  conditions  of  existence  are 
different  from  those  of  its  place  of  origin.  This  definition  of 
acclimatisation  applies  both  to  animals  and  plants.  As  regards 
the  acclimatisation  of  human  beings  it  is  also  required  that  they 
should  retain  in  a  foreign  country  and  under  altered  conditions 
of  life  their  previous  ability  to  live  physically  and  mentally  and 
to  continue  their  activity  without  any  detriment  to  their  health 
and  energy.  Where  a  whole  group  of  individuals  of  the  same 
class  is  concerned,  a  further  requirement  is  that  the  duration  of 
life  and  the  mortality  among  them  and  their  offspring  shall  not 
be  materially  different  from  those  prevalent  among  the  natives, 
and  that  they  retain  as  colonists  the  faculty  to  multiply  them- 
selves in  the  usual  manner  and  to  procreate  a  numerous  and 
healthy  offspring  capable  of  resisting  the  vicissitudes  of  life 
without  the  introduction  of  fresh  blood  or  a  constant  advent  of 
European  emigrants.  The  number  of  births  must  exceed  that 
of  the  deaths. 

These  are  the  points  of  view  from  which  scientists 
look  at  the  subject.  In  reality,  acclimatisation  depends 
to  a  great  extent  also  upon  economic  and  political  con- 


128  HEALTH,  DISEASE,  MARRIAGE 

ditions.  Religious  scruples  also  are  often  an  unfavour- 
able element  in  the  settlement  of  emigrants,  and  simi- 
larly disadvantageous  is  the  more  or  less  comfortable 
mode  of  life  to  which  they  were  accustomed  in  the  old 
country.  It  is  chiefly  the  women  who  find  it  very  diffi- 
cult to  accommodate  themselves  to  the  new  household 
arrangements  and  the  new  kind  of  domestic  servants; 
and  then  there  is  the  question  as  to  the  bringing  up  and 
the  education  of  the  children.  With  these  subjects  we 
are  of  course  not  concerned  here. 

It  is  necessary  to  point  out  that  individuals  as  such  may  find 
it  fairly  easy  to  accommodate  themselves  to  the  new  conditions 
but  that  it  does  not  follow  that  a  whole  group  of  individuals 
may  be  equally  successful.  For  this  reason  we  have  to  distinguish 
between  individual  acclimatisation  and  class  acclimatisation.  It 
is  chiefly  the  latter  which  shows  us  how  the  respective  influences 
have  been  at  work  through  a  long  series  of  generations  whose 
end-representatives  we  see  before  us  at  the  present  day.  Such 
race-acclimatisation  is  according  to  Hirsch  identical  with 
colonisation. 

The  French  call  the  natural  acclimatisation,  that  is 
the  one  which  individuals  undergo  without  any  measures 
on  their  part,  "acclimatement,"  and  the  substance  of 
the  measures  which  are  taken  for  the  purpose,  princi- 
pally the  hygienic  arrangements,  "acclimatation."  "Petit 
acclimatement"  they  call  the  individual  acclimatisation, 
and  "acclimatement  de  la  race"  that  of  a  whole  class 
or  race. 

The  test  of  accomplished  acclimatisation  is  therefore  the 
physical  thrift  and  the  multiplication  of  immigrated  colonists. 
When  they  succeed  in  living  like  the  natives  without  any  special 
aids,  they  are  said  to  be  naturalised. 

Acclimatisation  in  the  cold  and  temperate 
zones. —  The  acclimatisation  of  people  going  from  the  south 
to  the  north  takes  place  easily.  Plinius  and  Vitrwvius  already 
knew  this:  quae  a  frigidis  regionibus  corpora  traducuntur  in 
calida,  non  possunt  durare,  sed  dissolvuntur;  quae  autem  ex 
calidis  locis  subseptentrionum  regiones  frigidas,  non  modo  non 


CLIMATE,  RACE  AND  NATIONALITY       129 

laborant  immutatione  loci  valetudinibus,  sed  etiam  confirmantur. 
It  is  always  easier  to  protect  oneself  against  cold  than  against 
intense  and  persistent  heat.  The  regulating  apparatus  is  more 
adapted  to  deal  with  the  former  than  with  the  latter;  in  addition, 
there  are  no  endemic  diseases  to  contend  against. 

Coloured  individuals  (Indians  and  Negroes)   com- 
ing in  ships  right  from  the  tropics  into  our  winter  bear 
the  temporary  cold  very  well  and  without  injury.    The 
negroes  in  the  United  States  have  shown  themselves 
highly    capable    of    acclimatisation    under    favourable 
social  conditions.   The  prosperous  population  of  Lower 
Canada  is  to  the  extent  of  about  85%  of  French  descent. 
Some  authors  maintain  as  a  matter  of  course  that  inhabi- 
tants of  the  tropics  as  a  rule  accommodate  themselves  more 
easily  to  the  temperate  climates  than  vice-versa  the  inhabitants 
of  the  latter  to  the  tropics. 

Yet  this  cannot  be  said  to  be  generally  the  case.  A 
regiment  of  negroes  stationed  in  1817  in  Gibraltar  was 
almost  totally  destroyed  by  phthisis  within  15  months. 
The  wholesale  settlement  of  negroes  in  the  Antilles  was 
also  unsuccessful;  the  annual  average  population  of  the 
same  in  the  years  1816-1832  was  696,171;  of  these 
345,320  were  males  and  350,851  females;  to  100  births 
there  were  however  1 1 1  deaths  so  that  the  black  popu- 
lation was  bound  to  diminish  considerably  in  the  course 
of  time. 

In  any  case  there  is  in  reality  an  immediate  interchange 
possible  between  the  populations  of  the  tropics  and  those  of  the 
temperate  or  cold  zones.  The  inhabitants  of  the  tropics  have 
hardly  any  desire  to  emigrate  to  regions  where  they  would  have 
more  work  to  do  and  under  worse  climatic  conditions.  On  the 
other  hand  the  fertility  of  the  tropics  has  since  the  time  of 
their  discovery  ever  been  a  source  of  great  attraction  to  the 
civilised  nations  of  Europe. 

The  examination  into  the  possibility  of  acclimatisation  on 
the  part  of  a  race  or  a  nation  is  therefore  limited  in  practice 
to  the  question  of  the  acclimatisation  of  Europeans,  as  it  is 
almost  exclusively  nations  of  that  continent  and  belonging  to 


130  HEALTH,  DISEASE,  MARRIAGE 

the  "white"  race  that  are  striving  to  colonise  the  territories 
inhabited  by  weaker  races  or  possessing  sparse  populations.  The 
present  day  means  of  communication  greatly  facilitate  rapid 
changes  of  domicile. 

The  climate  of  the  tropics. — Travellers  who  make 
a  temporary  stay  in  the  tropics  experience  there  the  same  dis- 
comforts, but  to  a  much  greater  extent,  as  are  experienced  in  our 
latitudes  during  equally  hot  days.  The  enjoyment  of  the  mani- 
fold beauties  and  of  the  luxuriance  of  nature  is  very  much 
marred  by  the  physical  fatigue,  by  intense  perspiration,  by  an 
easily  supervening  sense  of  lassitude  and  by  the  constant  fear 
of  succumbing  to  some  more  or  less  serious  disease.  One  has 
always  the  feeling  that  it  is  not  given  to  man  to  walk  among 
palms  with  impunity.  Immigrants  who  have  to  endure  perma- 
nently the  influences  of  the  tropics  undergo  many  changes,  both 
physical  and  psychical,  some  of  a  general  kind  which  affect  the 
whole  human  organism,  and  others  which  are  of  a  more  indi- 
vidual character  and  dependent  upon  sex,  material  circumstances 
or  occupation.  At  the  beginning  of  their  sojourn  in  the  tropics, 
immigrants  feel  well  and  strong  for  a  short  time  only ;  for  soon 
they  commence  to  look  weak  and  pale,  their  physical  capability 
diminishes  and  their  previous  enjoyment  of  life  lessens  con- 
siderably. 

Injurious  effects  of  the  tropical  climate. — 
The  experiences  of  the  British,  French  and  Dutch  governments 
with  regard  to  their  troops  consisting  of  Europeans  and  natives 
prove  by  figures  what  was  instinctively  felt  before  by  everyone, 
namely  that  the  mortality  of  the  European  populations  in 
tropical  countries  is  considerably  higher  than  at  home,  and 
also  very  much  higher  than  that  among  the  indigenous  inhabi- 
tants. 

The  mortality  among  English  soldiers  was  occa- 
sionally 4  times  as  great  as  that  of  the  black  troops; 
and  it  has  even  happened  that  the  European  troops 
perished  almost  to  a  man  while  the  natives  or  the  troops 
related  to  them  remained  almost  entirely  free  from 
disease. 

In  France  the  mortality  among  the  military  during 


CLIMATE,  RACE  AND  NATIONALITY       131 

the  last  few  years  has  been  7.6  per  thousand;  whereas 
in  Algiers  and  Tunis  in   1883-1884  it  was   n.6  per 
thousand,  in  Cochin-China  in  1862,  91.8  per  thousand 
and  in  Senegambia  526.9  per  thousand. 
The  morbidity  also  is  considerably  higher  in  these  tropical 
regions. 

Of  1,000  persons  in  the  Britsh  Navy  in  the  year 
1889  the  following  were  attacked  by  disease: 

In  English  Stations  75,  in  West-African  Stations 
122,  In  West-Indian  Stations  104,  in  East-Indian  Sta- 
tions 158. 

In  the   period  of    1878-1882,   there   were  on   the 
daily  sick-list  in  the  Indian  army,   Europeans  56  per 
thousand  and  natives  44  per  thousand. 
The  diminished  resistibility  against  the  influences  of  the 
climate  is  apparent  not  only  in  the  immigrants  alone  but  also 
in  the  next  generation.   According  to  the  principles  of  heredity, 
such  a  rapid  change  and  adaptation  could  hardly  be  expected;  if 
an  adaptation  takes  place  at  all  it  can  only  be  achieved  in  the 
course  of  many  generations. 

The  infantile  mortality  among  the  military  popula- 
tion of  India  is  very  great;  in  1870-80  it  was  about 
70  p.er  thousand  against  22  per  thousand  in  London. 
Major  Bagnold  was  of  the  opinion  that  in  spite  of  all 
attempts  no  regiment  in  India  was  able  to  bring  up  as 
many  children  as  were  required  to  replace  the  pipers 
and  drummers. 

Regulation  of  the  body=heat  in  the  tropics.— 
The  proper  regulation  of  the  temperature  of  the  body  is  the 
first  and  most  important  demand  made  on  the  newly-arrived 
immigrant  by  the  physiological  process  of  acclimatisation.1  The 
greater  warmth  and  the  greater  humidity  of  the  air,  both  of 
which  combined  are  the  principal  factors  in  the  climate  of  the 


,  Akklimatisation  u.  Tropenhygiene,  Weyl's  Hdbch.  d.  Hygiene, 
Bd.  I. — Scheubc,  Tropenklima  u.  -Physiologic,  Eulenburg's  Real-Encyclo- 
padie.  —  Ddubler,  Grundziige  der  Tropenhygiene,  1900.  —  Mense,  Tropische 
Gesundheitslehre  u.  Heilkunde,  1902. — Rubner,  Lehrbuch  der  Hygiene, 
1903. 


132  HEALTH,  DISEASE,  MARRIAGE 

tropics,  produce  an  effect  in  the  immigrated  European.  The 
latter  has  to  adjust  himself  by  means  of  the  regulating  appa- 
ratus contained  in  his  organism  to  conditions  to  which  the  native 
is  by  nature  accustomed. 

As  is  well  known,  there  are  in  the  tropics  permanently  high 
temperatures  which  are  further  subject  to  daily  exacerbations 
dependent  on  the  position  of  the  sun.  The  humidity  of  the  air 
which  is  in  Central  Europe  in  the  summer  only  10  mm.  is  in 
Zanzibar  22.5  mm.;  in  Batavia  21  mm.  at  a  mean  annual  tem- 
perature of  25.8°  (Centigrade).  According  to  Wermch  the 
relative  humidity  at  sea  and  on  the  coast  of  tropical  countries 
is  80%.  The  seasons  and  the  various  situations  (more  or  less 
remote  from  the  equator,  relative  height  above  the  level  of  the 
sea)  have  of  course  a  somewhat  modifying  effect  on  the  condi- 
tions just  mentioned. 

Wol-pert  and  Rubner  have  shown  that  in  a  relative  humidity 
of  60-62%  and  at  a  mean  temperature  reaching  occasionally  a 
maximum  of  25.7°  C.,  it  is  quite  possible  for  people  to  feel 
perfectly  well  and  to  perform  hard  work  without  any  interrup- 
tion in  the  evaporation  of  the  perspiration.  The  climatic  con- 
ditions of  some  altitudes  in  the  tropics  fall  under  this  head,  and 
in  these  localities  immigrated  Europeans  can  retain  their  former 
ability  to  work.  Where  there  is  a  possibility  of  an  undiminished 
elimination  of  water  it  is  possible  even  in  the  desert  of  Sahara 
where  the  air  is  so  dry  for  white  men  to  perform  long  and 
wearisome  journeys  on  foot,  which  they  could  not  possibly 
accomplish  without  danger  under  the  influence  of  such  high 
humidity  as  is  present  in  the  low-lands  or  on  the  sea-coast  of 
the  tropics. 

Comparison  of  Europeans  with  coloured 
races. — As  regards  the  lowlands  in  the  tropics  we  notice  how- 
ever that  there  are  marked  differences  between  the  immigrated 
Europeans  and  the  natives  with  reference  to  the  regulation  of 
the  body-temperature.  Light  work  causes  very  soon  in  the  Euro- 
pean considerable  fatigue,  while  the  negro  or  the  Malay  hardly 
experiences  any  discomfort;  the  coloured  people  eliminate  easily 
during  moderate  labour  a  greater  amount  of  heat  into  the 
surrounding  air;  at  the  same  time  their  skins  are  almost  dry, 


CLIMATE,  RACE  AND  NATIONALITY       133 

while  Europeans  perspire  very  freely.  Eykman  has  on  the  basis 
of  ordinary  and  not  by  any  means  extreme  circumstances  estab- 
lished by  figures  certain  facts  relating  to  these  existing  differ- 
ences. Thus  he  found  f.  i.  that  a  moderately  working  Malay 
excretes  through  the  urine  and  the  faeces  738  grammes  of  water, 
and  through  the  perspiration  1,577  grammes;  whereas  an 
European  under  similar  circumstances  excretes  1338  and  1730 
grammes  respectively.  The  former  eliminates  therefore  2315 
grammes  of  water,  and  the  latter  3068  grammes.1 

It  should  also  be  mentioned  here  that  coloured  races 
drink  very  little  and  that  they  secrete  much  less  urine 
than  Europeans,  who  endeavour  to  compensate  by 
copious  drinking  the  great  loss  of  water  they  suffer 
through  profuse  sweating.  In  any  case  there  is  a  great 
difference  noticeable  between  them  as  to  the  excretion  of 
water  for  the  purpose  of  regulating  the  temperature 
of  the  body. 

It  is  as  yet  a  much  debated  question  how  and  to  what  extent 
coloured  people  effect  the  elimination  of  their  watery  secretion. 
It  is  not  impossible  that  they  excrete  by  the  lungs  greater  quan- 
tities of  water  than  Europeans.  The  lung-capacity  of  the  Malay 
is  greater  in  proportion  to  their  stature,  and  it  has  also  been 
noticed  that  they  exhibit  an  increased  respiratory  frequency. 
The  commencement  of  the  respiratory  passages  in  the  negro  is 
more  voluminous  so  that  he  can  breathe  more  freely.  An 
increased  respiration  might  therefore  enhance  the  elimination 
of  watery  vapour. 

It  is  clear  that  the  skin  of  coloured  races  acts  differently  in 
respect  to  radiation  of  heat  and  secretion  of  sweat  than  does 
that  of  white  people.  During  a  time-unit  a  coloured  man  doing 
a  moderate  amount  of  work  eliminates  more  cutaneous  heat 
into  the  surrounding  air,  whereas  the  white  man  appears  to 
retain  the  heat  much  longer  in  his  skin. 

Glogner  found  that  one  square  centimeter  of  Malay 
skin  discharges  in  y2  hour  10.5  heat-units,  and  the  same 
surface  of  European  skin  only  8.7.  There  is,  besides,  a 


Kilogr.  of  water  forms  in  the  evaporation  572  large  calories. 


134  HEALTH,  DISEASE,  MARRIAGE 

small  difference  in  the  body  temperature,  which  is  37.20° 
C.  in  the  Malay,  and  37.33°  C.  in  the  European. 
European   immigrants   also   show   considerable   individual 
differences  in  the  elimination  of  heat,  which  is  not  the  case  in 
the  Malay.    Eykman  estimates  the  average  difference  in  the 
elimination  of  heat  through  radiation  and  conduction  between 
Malays  and  Europeans  as  4.7%  in  favour  of  the  Malays.  The 
same  thing  may  be  said  with  regard  to  negroes;  the  heat  pro- 
ceeding from  the  dry  skin  of  a  negro  is  perceptible  from  some 
little  distance. 

Anatomical  peculiarities  which  might  explain  the 
different  behaviour  of  the  skin  in  whites  and  in  coloured 
people  have  not  been  found.    Neither  the  observations 
of  Henle  and  Krause  that  the  skins  of  negroes  are 
thicker  than  those  of  the  Caucasian  race,  the  cutis  in 
general  varying  by  about  i  mm.  and  the  epidermis  in 
some  places  by  nearly  as  much,  nor  those  of  Daubler  to 
the  effect  that  coloured  skins  have  larger  sweat-glands 
and  sebaceous  glands  of  double  the  size  of  those  in 
white  skins,  are  of  any  practical  importance. 
In  contrast  with  coloured  people  who  are  by  nature  endowed 
with  special  means  to  regulate  their  temperature  in  accordance 
with  tropical  conditions,  the  whites  are  dependent  exclusively 
upon  the  increased  secretion  of  perspiration.   It  is  true  that  the 
organism  has  at  its  disposal  regulating  aids  which  act  independ- 
ently and  by  way  of  the  nervous  system.   When  the  body-tem- 
perature is  higher  the  capability  of  the  muscular  system  dimin- 
ishes, and  the  amount  of  body-heat  generated  decreases,  but 
with  it  decreases  also  the  ability  to  work.     If  under  circum- 
stances however  these  functions  do  not  co-operate  properly  or 
at  the  proper  time,  there  occurs  a  congestion  of  heat  which 
manifests  itself  by  insolation  or  other  pathological  conditions. 
By  an  increase  of  respiration  the  elimination  of  vapour  is  some- 
what assisted,  but  neither  by  this  means  nor  by  the  relaxation  in 
the  cutaneous  capillaries  is  much  heat  given  off. 

New-comers  perspire  very  freely  after  the  slightest  exer- 
tion; after  many  years  the  skin  becomes  accustomed  to  the 
altered  conditions  and  the  perspiration  is  less  profuse. 


CLIMATE,  RACE  AND  NATIONALITY       135 

Nutrition  in  the  tropics. — There  is  a  wide-spread 
belief  that  the  amount  of  nourishment  required  differs  materially 
in  different  climates,  and  that  particularly  in  the  tropics  far  less 
suffices  to  sustain  life.  Recent  research  has  shown  this  opinion 
to  be  wrong,  and  that  the  difference  is  only  a  very  slight 
one.1 

Under  the  influence  of  occasional  high  temperatures,  the 
appetite  of  an  European  diminishes  for  the  time  being;  where 
the  temperature  is  perpetually  high  the  appetite  may  also  be 
permanently  affected.  New  immigrants  lose  their  appetite  after 
a  very  short  stay  in  hot  places,  and  their  nutritive  requirements 
adapt  themselves  only  gradually.  It  is  impossible  to  state  a 
definite  temperature  at  which  this  anomaly  occurs,  as  it  varies 
in  different  individuals.2 

Requirement  of  -water  in  the  tropics. — The 
quantity  of  water  eliminated  principally  by  the  urine,  the  per- 
spiration and  evaporation  is  replaced  by  drinking.  The  thirst 
is  however  as  we  know  from  experience  even  in  the  temperate 
climate  of  Europe,  increased  by  drinking  and  the  tendency  is 
to  drink  more  cold  water  than  is  necessary.  Natives  prefer 
warm  drinks  such  as  coffee  and  tea  as  these  quench  the  thirst  in 
smaller  quantities  and  do  not  produce  the  evil  results  of  large 
quantities  of  water  such  as  profuse  sweating  which  irritates  the 
skin  and  wets  underlinen  and  clothes,  a  depressing  effect  on  the 
stomach  and  intestines,  and  an  increased  chance  to  catch  cold. 
The  blood-pressure  becomes  greater,  the  cutaneous  capillaries 
are  more  injected,  and  the  pleasing  sensation  experienced  during 
the  act  of  drinking  is  succeeded  by  a  general  unpleasant 
feeling  of  discomfort.  If  as  it  frequently  happens  alcohol  in 
some  more  or  less  concentrated  form  is  taken  instead  of  plain 
water,  and  the  opportunities  for  doing  so  are  not  absent,  the 
combined  effects  of  the  double  injury  soon  become  apparent. 
It  is  a  plausible  saying  that  one  should  quench  his  thirst  in  the 
tropics  not  by  glassfuls  but  by  spoonfuls. 


it,    Nahrung    in    den    verschiedenen    Klimaten,    Arch.    f.    Anthrol. 
Bd.  XXIII. 

*IV.    E.    Ranke,    Einwirkung    d.    Tropenklimas    auf    die    Ernahrung    d. 
Menschen.    1900. 


136  HEALTH,  DISEASE,  MARRIAGE 

Other  physiological  and  pathological  proc- 
esses in  tropical  acclimatisation. — We  have  already 
seen  that  one  of  the  consequences  of  the  equilibration  of  the 
body-heat  is  an  increase  in  the  respiratory  frequency.  In  new- 
comers it  amounts  to  20  or  more  respirations  per  minute;  in 
those  who  have  become  acclimatised  by  a  longer  stay  the  num- 
ber falls  and  is  about  16-20. 

According  to  Plehn  the  pulse  is  at  first  quickened  by  about 
6  beats,  after  a  time  it  is  in  the  European,  like  in  the  native, 
about  68-78  per  minute.  In  other  respects  there  is  no  change 
observed. 

The  same  author  has  found  that  the  body  temperature  is  in 
new-comers  on  an  average  0.46  degree  (C.)  higher,  and  that 
it  may  go  up  by  as  much  as  2  degrees.  After  acclimatisation 
there  is  no  increase  and  the  temperature  fluctuates  according  to 
seasons  between  0.18-0.4°. 

As  regards  the  vascular  system  there  is  a  tendency  to  con- 
gestion in  internal  organs  particularly  after  dietetic  errors  and 
especially  after  the  consumption  of  alcohol,  also  after  severe 
exertion. 

The  heart  is  in  consequence  of  these  various  processes 
severely  affected  either  primarily  or  secondarily.  There  is  hardly 
an  European  who  does  not  when  visiting  the  tropics  suffer  from 
an  irritability  of  this  organ.  In  those  acclimatised  the  heart  and 
the  blood-vessels  adapt  themselves  to  the  changed  conditions,  so 
that  nothing  abnormal  can  be  detected.  Though  this  happens 
frequently,  one  meets  on  the  other  hand  many  Europeans  in 
the  tropics  whose  hearts  are  functionally  weak  or  exhibit  irregu- 
larities, such  as  light  dilatation;  occasionally  functional  mur- 
murs are  heard  which  appear  especially  after  exertion. 

The  liver  especially  is  in  the  tropics  an  organ  to  which 
during  congestion  the  circulation  looks  for  an  outlet.  The  liver, 
both  in  immigrants  and  natives,  contains  more  blood  than  in 
temperate  climates.  Immediately  after  arrival  in  the  tropics  the 
liver  begins  to  grow  in  volume,  perhaps  in  consequence  of  the 
larger  quantity  of  fluids  consumed;  but  this  enlargement,  which 
is  often  insignificant  only,  remains  permanent  without  causing 
any  sort  of  trouble.  This  enlargement  of  the  liver  was  formerly 


CLIMATE,  RACE  AND  NATIONALITY       137 

a  subject  of  fabulous  importance  with  regard  to  acclimatisation 
in  the  tropics.  It  was  supposed  to  be  productive  of  larger 
quantities  of  bile,  which  is  not  a  fact;  it  was  suspected  that  on 
account  of  the  enlargement  of  the  liver  in  the  tropics  the  pul- 
monary capacity  is  diminished,  (a  condition  which  has  not 
been  proved)  and  that  the  liver  acts  therefore  as  a  sort  of 
vicarious  organ,  being  accordingly  styled  "the  lung"  of  hot 
climates.  From  a  pathological  point  of  view  the  liver  in  the 
tropics  certainly  demands  the  frequent  attention  of  the  medical 
man,  seeing  that  disturbances  take  place  in  this  organ  which 
are  caused  by  alcohol,  malarial  infection,  dysentery,  various 
micro-organisms,  animal  parasites,  etc.  so  that  these  disturbances 
must  be  attributed  less  to  the  climate  than  to  an  unhygienic 
mode  of  life  or  to  a  pathogenic  infection. 

The  secretion  of  urine  in  the  tropics  is  diminished  in  con- 
sequence of  the  increased  elimination  of  water  through  other 
channels.  For  this  reason  it  is  also  not  possible  to  give  figures 
with  regard  to  the  daily  secretion  of  urine.  When  perspiration 
is  very  profuse,  about  700  ccm.  of  urine,  or  even  less  are  dis- 
charged daily;  otherwise  about  I  litre  is  the  usual  quantity.  As 
the  amount  of  urine  diminishes,  so  does  its  specific  gravity  go 
up,  and  the  latter  fluctuates  between  1018-1024.  The  quantity 
and  specific  gravity  of  the  urine  and  sweat  depend  of  course 
on  the  amount  of  fluid  consumed. 

Urinary  substances  are  eliminated  both  by  the  urine  and  the 
perspiration.  The  quantity  of  the  products  secreted  as  a  result 
of  metabolism  is  about  the  same  in  the  tropics  as  in  temperate 
countries.  Some  statements  that  less  nitrogen  is  eliminated 
through  the  urine  may  be  explained  by  the  neglect  to  take  into 
account  the  quantity  eliminated  through  the  perspiration. 
According  to  Eykman  after  light  work  about  12.8  grammes  of 
nitrogen  are  on  an  average  daily  eliminated  through  the  urine, 
and  0.76-1.36  gr.  through  the  skin.  The  acclimatised  European 
discharges  therefore  quantitatively  hardly  any  less  nitrogen  than 
the  inhabitants  of  temperate  climates,  only  he  discharges  it  in 
a  different  manner. 

Both  voluntary  and  involuntary  muscles  are  affected  by  the 
relaxing  and  debilitating  influence  of  the  tropical  climate.  This 


138  HEALTH,  DISEASE,  MARRIAGE 

is  seen  in  the  lesser  working  ability  of  Europeans  compared  to 
the  natives,  and  may  be  demonstrated  by  means  of  the  dyna- 
mometer. 

The  opinion  already  expressed  by  Lavoisier  that  the  excre- 
tion of  carbonic  acid  is  diminished  in  hot  countries  has  recently 
been  experimentally  proved  by  Rubner  to  be  correct. 

As  regards  the  consumption  of  oxygen  the  views  hitherto 
existing  on  the  basis  of  theoretical  calculations  have  turned  out 
to  be  erroneous.  Owing  to  the  higher  temperature,  both  air  and 
gases  are  expanded;  a  definite  volume  of  air  contains  therefore 
less  oxygen  than  in  cooler  regions.  The  higher  percentage  of 
vapour  contained  in  the  tropical  atmosphere  also  contributes  to 
a  further  quantitative  reduction  of  oxygen.  It  was  consequently 
assumed  that  the  consumption  of  oxygen  in  hot  countries  is 
diminished  and  an  attempt  was  made  to  find  the  cause  of  tropical 
ansmia  in  the  reduced  quantity  of  oxygen  contained  in  the 
inspired  air.  It  was  however  overlooked  that  the  inspired  air, 
no  matter  how  constituted,  is  in  all  climates  warmed  first  in  the 
respiratory  passages  to  about  the  same  degree  (that  is  35°  C.) 
and  well  mixed  with  vapour.  The  amount  of  oxygen  which  can 
still  be  taken  up  in  accordance  with  physical  laws  is  sufficiently 
present  in  the  air  of  the  tropics.  Moreover  examinations  of  the 
blood  have  shown  that  the  number  of  red  and  white  corpuscles, 
and  the  quantity  of  haemoglobin  are  by  no  means  always  dimin- 
ished in  the  tropics.  The  anaemia  is  not  necessarily  a  result  of 
the  stay  in  the  tropics;  if  it  is  seen  frequently,  there  may  be 
pathological  and  other  reasons,  physical,  nervous  and  moral 
present. 

One  meets  in  hot  countries  very  often  people  with  a  pro- 
nounced grey-yellowish  and  sallow  complexion,  and  healthy- 
looking  immigrants  acquire  in  the  course  of  time  such  an  appear- 
ance. The  condition  has  been  given  the  special  name  of  tropical 
anaemia,  but  examinations  of  the  blood  have  revealed  no  definite 
changes  in  the  normal  elements  of  the  haemoglobin,  in  the 
specific  gravity,  or  in  the  amount  of  water  contained  in  the 
blood  (Mares tang,  Eykman,  Glogner,  Plehn)  provided  of 
course  there  was  no  real  anaemia  in  consequence  of  malaria, 
chronic  diarrhoea,  dysentery,  ankylostomiasis  or  some  other 


139 

cause.  Tropical  anaemia  is  now  regarded  as  a  normal  condition 
of  the  skin,  the  pigmentation  of  which  is  influenced  by  the  altered 
conditions  in  the  circulation,  secretion  and  illumination.  Owing 
to  the  antagonistic  hyperaemia  in  the  abdominal  organs  (Stokvis, 
v.  d.  Scheer]  the  cutaneous  capillaries  are  less  injected,  the  upper 
cellular  layers  of  the  skin  are  on  account  of  the  increased  activity 
of  this  organ  added  to  and  saturated  with  moisture;  the  horny 
layer  of  the  epidermis  swells  and  obstructs  the  transparency  of 
the  redness  of  the  capillaries  which  would  give  the  skin  a  rosy 
appearance  in  temperate  climates.  Besides,  the  inhabitants  of 
the  tropics  and  particularly  the  women  avoid  as  a  rule  with 
a  kind  of  fear  the  direct  influence  of  the  sun. 

The  nervous  system  is  during  the  transition  period,  and  also 
during  the  stay  in  hot  countries  severely  affected  through  the 
physiological  processes  discussed  above,  even  where  they  occa- 
sion no  disturbances.  Almost  always  and  with  rare  exceptions 
there  appear  signs  of  a  more  or  less  well-marked  neurasthenia 
and  in  connection  with  it  distressing  insomnia,  susceptibility  to 
mental  impressions,  nervous  irritability,  finally  apathy,  moral 
depression,  defects  of  memory,  and  similar  consequences.  Every 
mental  exertion  requires  in  the  tropics  a  special  amount  of  energy 
different  in  a  subjective  degree.  The  advance  in  the  civilisation 
of  China,  Japan,  India,  Australia,  and  South  America  shows 
that  a  certain  amount  of  mental  productiveness  is  possible  in 
hot  countries,  but  such  progress  as  has  been  achieved  by  com- 
munities in  temperate  climates  can  hardly  be  expected  from  the 
tropics;  and  it  is  very  unlikely  that  they  will  ever  supply 
humanity  with  original  and  profound  thinkers  or  investigators. 

The  increased  irritability  manifests  itself  also  in  the  sexual 
life.  The  desire  in  both  sexes  is  increased,  and  the  fruitfulness 
of  the  man  greater.  Altogether  the  conditions  of  life  and  the 
daily  events  are  greatly  under  the  influence  of  sexual  excitement 
both  in  a  good  and  a  bad  sense.  There  seems  to  be  no  theoretical 
reason  why  morality  should  suffer,  but  as  a  matter  of  fact  there 
is  a  great  deal  of  transgression  under  the  tropical  sun  committed 
against  connubial  and  non-connubial  conditions.  With  regard 
to  Africa  specially  a  condition  has  been  created  under  the  name 
of  "tropical  frenzy,"  but  the  probability  is  that  individuals 


140 

unable  to  control  themselves  when  away  from  the  watchful  eye 
of  the  law  and  of  society  would  lose  their  equilibrium  even  at 
the  North  Pole. 

The  digestive  organs  also  exhibit  manifold  deviations.  The 
digestive  juices  are  more  fluid  and  consequently  less  effective; 
the  muscular  coats  of  the  stomach  and  intestines  become  more 
lax.  Numerous  micro-organisms  which  thrive  abundantly  in  the 
moist  tropical  climate  are  introduced  into  the  digestive  tract 
along  with  the  solid  and  liquid  ingesta.  Atonic  gastric  com- 
plaints and  hypochlorhydria  are  frequently  observed.  The 
digestion  of  proteids  is  often  interfered  with;  and  a  diminished 
desire  for  animal  food  manifests  itself.  Intestinal  catarrhs  and 
constipation  are  frequent  complaints  resulting  from  atony  of  the 
bowels  or  from  an  increased  loss  of  water  through  perspiration. 

Digestive  disturbances,  anaemia,  and  neuroses  influence  each 
other  reciprocally  in  the  tropics  in  the  same  way  as  they  do  in 
temperate  climates. 

The  statements  that  a  slight  hypertrophy  of  the  left  ven- 
tricle occurs  constantly  in  consequence  of  the  increased  cardiac 
activity,  diminished  secretion  of  urine  and  greater  arterial  pres- 
sure (Martin),  and  that  an  acclimatisation-atrophy  of  the 
kidneys,  especially  of  the  cortical  substance,  is  caused  by  the 
diminished  urinary  secretion,  have  received  no  confirmation. 

Finally  it  is  worth  mentioning  that  the  skin  becomes  in  tha 
tropics  much  more  sensitive,  and  that  it  is  affected  by  even 
insignificant  changes  in  the  temperature.  Diseases  caused  by 
cold  and  especially  rheumatism  in  different  forms  and  degrees 
of  severity  threaten  every  inhabitant  of  the  tropics. 

Mass  acclimatisation. — In  looking  back  at  the  most 
important  changes  mentioned  above  which  the  organism  of  the 
immigrant  has  to  undergo  under  the  influence  of  the  tropical 
climate  we  see  that  a  considerable  demand  is  made  upon  the 
physiological  capability  of  each  individual.  If  such  individuals 
succeed  singly  in  accommodating  themselves  it  does  not  follow, 
as  I  have  already  said  that  a  large  number  of  colonists  coming 
from  a  similar  stock  would  be  equally  successful  in  settling  in 
the  tropics  and  there  founding  families  and  generations.  In  the 
course  of  the  physiological  process  of  acclimatisation  there  are 


CLIMATE,  RACE  AND  NATIONALITY       141 

numerous  transitions  to  pathological  conditions,  and  whereas 
travellers  and  scientists  formerly  believed  that  the  acclimatisa- 
tion of  white  races  in  the  tropics  is  impossible,  or  at  least  possible 
in  the  case  of  certain  European  nations  only,  among  which  the 
Germans  were  certainly  not  included,  this  opinion  has  during 
the  last  two  decades  undergone  considerable  modification.  It  is 
important  that  this  modified  view  is  shared  by  doctors,  natural- 
ists, and  officials  who  speak  from  personal  experience  which 
they  obtained  in  the  tropics.1  The  prospects  that  Europeans 
can  settle  fully  and  completely  in  hot  climates  have  improved 
materially;  but  whether  they  will  be  able  to  accomplish  all 
physical  labour  equally  with  the  natives  is  a  question  which  the 
future  only  can  decide. 

Favourable  predisposition. — There  are  elements 
favoured  by  nature  which  have  apparently  no  inclination  to  be 
attacked  by  endemic  diseases,  and  especially  by  malaria,  and 
which  if  attacked  can  overcome  the  maladies  without  any  serious 
consequences.  Such  are  youthful,  healthy  and  vigorous  elements 
not  hereditarily  predisposed  to  disease.  For  the  Germanic  race 
it  appears  that  the  most  suitable  age  for  acclimatisation  is  that 
between  23  and  40;  for  the  Roman  race  the  individual  suita- 
bility begins  much  earlier,  namely  at  16.  Those  who  have  previ- 
ously trained  their  bodies  by  gymnastics  or  other  physical  exer- 
cise are  generally  speaking  better  adapted.  Infants  die  easily 
from  the  consequences  of  dentition  or  digestive  disturbances; 
too  young  people  are  not  sufficiently  hardened  against  the  unac- 
customed fatigues  and  the  new  conditions  of  an  altered  mode 
of  life;  they  soon  become  anaemic  and  fall  a  prey  principally  to 
malaria;  older  people  are  no  longer  sufficiently  elastic. 

Predisposition  of  females. — It  cannot  be  denied 
that  European  women  are  on  the  whole  more  susceptible  to  the 
climatic  influence  of  the  tropics  than  the  men.  Those  whose 
bodies  have  become  hardened  through  work  and  physical 
activity  are  in  a  more  favourable  position.  The  case  is  however 
different  in  those  women  who  emigrate  as  daughters  or  wives 
along  with  their  fathers  or  husbands  without  any  regard  to 


lWulffert,  Akklimat.  d.  Europ.  u.  insbes.  d.  german.  Rasse  in  d.  Tropen, 
u.  ihre  haupts.  Hindernisse  v.  Volkmann's  Samml.  klin.  Vortrage.  No.  279. 


142  HEALTH,  DISEASE,  MARRIAGE 

their  physical  fitness.  Under  the  influence  of  the  climate  and 
among  unaccustomed  surroundings  they  soon  become  anaemic 
and  nervous ;  uncommonly  frequent  are  menstrual  disturbances. 
Older  opinions  were  to  the  effect  that  all  European  women 
living  in  the  tropics  suffer  from  leucorrhoea;  and  though  this 
may  not  be  quite  true,  the  malady  is  in  any  case  exceedingly 
prevalent.  It  is  found  that  females  do  not  suffer  so  much  from 
malaria,  but  this  is  probably  due  to  their  more  domestic  employ- 
ment. 

Sexual  life  and  marriage  of  Europeans. — 
These  women  show  themselves  unequal  to  the  demands  of 
married  life;  they  easily  miscarry.  Young  mothers  as  a  rule 
lose  their  milk.  Further,  endometritic  diseases  are  very  preva- 
lent and  they  lead  to  all  kinds  of  uterine  disturbances,  to 
amenorrhcea,  menorrhagias  and  sterility.  In  addition,  the 
general  condition  of  the  women  deteriorates,  they  become 
emaciated,  the  nervous  life  and  the  regulated  psychical  state  are 
disturbed,  and  the  married  life  of  Europeans  is  therefore  often 
a  sad  one.  Whilst  the  sexual  requirements  of  the  husband  are 
in  the  tropics  greater  the  resistibility  of  the  wife  diminishes. 
But  although  these  distressing  conditions  are  very  frequent, 
especially  in  the  case  of  young  women  who  have  come  to  the 
tropics  direct  from  well-regulated  European  surroundings  to 
find  in  the  place  of  the  expected  bliss  serious  disappointments, 
there  are  nevertheless  females  who  accommodate  themselves 
perfectly  to  married  life  as  wives  and  mothers. 

It  has  formerly  been  asserted  that  the  fruitfulness  of  Euro- 
peans in  the  tropics  diminishes  and  that  it  does  not  go  beyond 
the  fourth  generation.  I  will  deal  later  more  fully  with  this 
assertion;  for  the  present  I  wish  to  observe  that  owing  to  the 
chronic  indisposition  of  the  European  women  the  men  are  often 
induced  to  have  recourse  to  healthy  natives.  Hence  the  accli- 
matisation of  the  European  race  is  often  frustrated  on  the  one 
hand  by  the  sexual  incapacity  of  the  women,  and  on  the  other 
it  gives  rise  to  various  mixed  races. 

The  main  reason  however  why  a  continuation  over  several 
generations  of  descendants  of  an  unmixed  European  race  is  so 
rare  in  the  tropics  lies  undoubtedly  in  social  conditions.  The 


CLIMATE,  RACE  AND  NATIONALITY       143 

formation  of  a  household  is  to  the  immigrant  an  encumbrance, 
and  an  impediment  which  prevents  free  movements.  Many  a 
married  European  finds  difficulties  in  educating  his  children; 
he  therefore  sends  his  family  to  Europe  or  returns  there  himself. 
Others  do  not  feel  the  want  of  European  family  life  and  prefer 
a  native  woman;  no  longer  accustomed  to  the  restraint  neces- 
sitated by  intercourse  with  civilised  women,  they  find  an  efficient 
substitute  in  the  free  mode  of  living  with  natives  to  whom  they 
need  pay  no  consideration.  The  offspring  mix  with  the  native 
children  from  among  whom  they  naturally  select  their  sexual 
companions. 

Tropical  climate  at  the  coast,  in  the  interior, 
on  islands  and  on  the  mountains. — The  considera- 
tion of  the  peculiarities  of  the  tropical  climate  must  take  place 
from  various  points  of  view.  Most  emigrants  going  out  inde- 
pendently proceed  to  places  on  the  coast,  where  the  hygienic 
conditions  are  none  of  the  best  and  in  addition  to  the  high  tem- 
perature the  atmosphere  is  very  moist.  The  insular  climate  in 
the  tropics  is  similarly  constituted  and  its  effect  is  equally 
depressing. 

Different  however  from  this  moist-hot  climate  which  acts 
as  an  obstacle  against  acclimatisation,  is  from  the  practical 
standpoint  the  more  favourable  dry  climate  of  the  interior; 
there  the  relative  humidity  in  the  dry  and  wet  seasons  varies 
considerably,  but  is  not  permanently  as  great  as  on  the  coast. 

The  most  favourable  climate  is  that  of  the  mountainous 
regions.  The  higher  the  zone  the  more  it  approaches  the  Euro- 
pean climate.  Jacob  Lindt  as  early  as  1770,  called  attention 
to  the  difference  in  the  climates  of  the  highlands,  islands  and 
valleys  of  tropical  countries,  and  shewed  how  differently  they 
affect  the  health.  But  only  recently  attempts  have  been  made 
to  take  advantage  of  this  fact  by  settling  colonists  in  high 
localities  or  by  utilising  to  the  greatest  possible  extent  for  dwell- 
ing places  elevated  districts  in  the  neighbourhood  of  the  coast- 
towns. 

But  though  there  are  no  endemic  diseases,  such  as  malaria, 
yellow  fever,  dysentery,  etc.  present  in  elevated  districts,  and 
the  feeling  of  comfort  is  greater,  there  are  nevertheless  com- 


i44  HEALTH,  DISEASE,  MARRIAGE 

plaints  among  the  Europeans,  such  as  anaemia,  sterility  of  the 
women,  great  loss  of  child-life;  they  also  manifest  an  inclination 
to  inflammatory  and  catarrhal  diseases. 

Hygiene  in  the  tropics. — The  possibility  of  accli- 
matisation on  the  part  of  single  individuals  as  well  as  entire 
colonies  owes  a  great  deal  to  the  progress  which  the  hygiene 
of  the  tropics  has  made  in  the  last  two  decades.  Whereas 
formerly  everything  was  done  empirically  it  is  now  recognised 
that  a  definite  system  must  be  followed  how  and  where  hygiene 
is  to  interfere.  Special  and  rational  rules  have  been  adopted 
with  regard  to  agriculture,  irrigation,  housing  arrangements, 
etc. ;  suitable  principles  are  acted  upon  as  to  clothing,  nutrition, 
recreation,  physical  culture  in  the  healthy  and  unhealthy  condi- 
tion, and  though  much  remains  yet  to  be  done,  much  has  already 
been  accomplished.  Hiippe1  is  right  in  saying:  "The  main  diffi- 
culty of  acclimatisation  in  the  tropics  no  longer  lies  in  the  ques- 
tion of  adaptability,  but  in  the  question  of  personal  and  public 
hygiene.  The  problem  of  the  acclimatisation  of  Europeans  in 
the  tropics  has  been  replaced  by  the  problem  of  the  hygiene  of 
Europeans  in  the  tropics." 

Consumption  of  alcohol. — A  few  words  with  regard 
to  the  injurious  influence  of  alcohol  may  be  indicated  here. 
Emin  Pasha,  doubtless  an  authority  on  questions  connected  with 
the  tropics,  said :  "Those  who  avoid  all  excesses,  and  especially 
the  abuse  of  alcoholic  liquor,  can  afford  to  laugh  at  the  fairy- 
tales on  the  dangers  of  the  tropical  climate."  He  thinks  that 
Europeans  suffer  from  it  so  much  just  because  they  cannot  keep 
off  intoxicating  liquors.  All  experiences  agree  upon  the  injuri- 
ousness  of  an  excess  of  alcohol,  no  matter  in  what  form  indulged 
in,  upon  the  physical  as  well  as  the  moral  condition ;  it  is  indeed 
an  obstacle  against  acclimatisation  if  not  a  downright  cause  of 
diseases  which  tend  to  shorten  life.  Wultfert  sees  the  principal 
dangers  of  alcoholic  abuse  in  its  effects  upon  the  digestive,  ner- 
vous and  vascular  systems,  in  the  disturbance  of  the  physical 
regulation  of  the  body-temperature,  and  the  diminished  resisti- 
bility  of  the  body  against  disease-producing  micro-organisms. 


'Berl.  Klin.  Woch.  1901. 


CLIMATE,  RACE  AND  NATIONALITY       145 

Whites  who  are  given  to  the  drinking-habit  will 
never  become  acclimatised  in  tropical  conditions.  Fiebig1 
gives  examples  from  the  Dutch-Indian  army,  especially 
during  the  campaign  against  Atjeh  in  1898,  showing 
that  European  abstainers  in  the  tropics  proved  more  fit 
than  the  natives. 

Acclimatisation  of  races. — In  a  lecture  on  accli- 
matisation2 Firchow  said:  "In  medical  circles  no  one  has  ever 
imagined  anything  else  but  that  such  an  adaptation  is  connected 
with  material  alteration  of  the  organism,  that  it  is  not  there- 
fore a  question  of  a  mere  change  of  outer  costume,  but  of  an 
internal  transformation  creating  to  some  extent  entirely  new 
organic  conditions.  In  the  course  of  time  an  habituation  takes 
place  whereby  the  number  of  diseases  and  deaths  occasioned  by 
the  climatic  conditions  undergoes  diminution."  In  another  place 
Firchow*  said:  "There  is  an  acclimatisation  but  a  limited  one. 
Certain  races  are  more  adapted  for  acclimatisation  and  others 
less  so."  The  latter  he  called  vulnerable  and  these  are  absolutely 
unsuitable  for  the  colonisation  of  tropical  regions.  On  the  other 
hand  Weissmann  maintained  that  the  favourable  individual 
variations  present  in  a  colony  persist  and  are  propagated  and 
that  they  can  transmit  their  favourable  qualities  to  their  off- 
spring. Thus  racial  acclimatisation  is  accomplished.  The  less 
resistible  succumb,  the  more  resistible  endure  and  transmit  their 
greater  resistibility  to  their  descendants.  It  is  therefore  a  ques- 
tion of  "natural  selection,"  and  the  query  arises:  Is  racial  accli- 
matisation accomplished  by  favoured  individuals  of  a  particular 
race  or  by  favoured  individuals  of  any  one  race,  in  other 
words,  are  there  with  regard  to  acclimatisation,  privileged 
races? 

Among  Mongolian  nations  the  Chinese  have  endeavoured 
to  form  independent  colonies  and  have  succeeded  in  spreading 
themselves  over  the  Asiatic  and  Australian  continents  as  well  as 
Polynesia.  On  account  of  the  different  climates  of  their  country 
which  stretches  from  the  Siberian  border  to  beyond  the  tropics 


fur    Schiffs-   u.    Tropenhygiene.     1901. 
2LVIII.  Deutsche  Naturforscherversammlung. 
'Arch.  f.  path.  Anat.  Vol.  103.  Descendenz  u.  Pathologic. 


146  HEALTH,  DISEASE,  MARRIAGE 

they  have  in  the  course  of  time  acquired  a  certain  resistibility. 
They  have  shown  themselves  superior  to  the  white  colonists 
because  they  have  easily  assimilated  with  the  native  races  of 
all  countries  where  they  settled  and  formed  numerous  mixed 
products. 

The  coloured  races  have  as  a  rule  been  transplanted  against 
their  will  and  consequently  become  acclimatised  under  unfa- 
vourable circumstances,  in  a  State  of  subjugation,  without  the 
help  of  hygienic  precautions,  perhaps  because  the  movements 
always  took  place  towards  tropical  and  sub-tropical  regions  with 
a  climate  resembling  that  of  their  original  home.  An  acclimatisa- 
tion of  mid-African  negroes  in  the  coast-lands  of  North  Africa, 
in  Egypt,  Tunis,  Tripoli,  Morocco,  Algeria  has  never  been 
possible,  and  similarly  the  transportation  of  negroes  to  Ceylon, 
Mauritius,  the  West-Indies,  Mexico,  and  other  such  places 
whose  climate  ought  to  have  suited  them,  has  also  proved  futile ; 
it  is  of  course  possible  that  the  miserable  treatment  which  they 
received  is  accountable  for  these  failures. 

What  climatic  differences  may  come  into  question 
with  regard  to   acclimatisation   is  seen   in   the   horse, 
which  is  not  adapted  to  the  damp  and  warm  climate 
of  the  tropics,  but  which  thrives  in  hot  and  dry  countries, 
such  as  Arabia,  North  Africa,  Australia,  etc. 
In  the  tropical  parts  of  South  America,  in  the  Antilles,  and 
in  the  south  of  the  United  States  the  negro  race  prospers,  thrives 
and  is  reproductive;  it  has  even  penetrated  farther  north  and 
also  changed  its  physiognomy,  the  cheek-bones  are  less  promi- 
nent, the  lips  not  quite  so  thick  and  the  nose  less  flat,  the  woolly 
hair  is  not  so  profuse  and  the  angle  of  the  face  not  so  acute  as 
in  the  African  negro  (Bastian} . 

Wherever  the  negro  race  appeared  it  mixed  willingly  or 
unwillingly  with  people  of  their  own  kind  or  with  those  of 
other  races,  as  is  seen  by  the  numerous  half-breeds  in  existence. 
In  respect  to  physiological  functions  and  mode  of  life,  as  well 
as  in  the  manner  of  geographical  distribution,  the  Arabs  approxi- 
mate very  much  the  negro  type. 

Special  examples  of  pure  racial  acclimatisation  we  find  in  the 
Jews  and  the  gypsies  who  have  that  in  common  between  them 


CLIMATE,  RACE  AND  NATIONALITY       147 

that  they  generally  try  to  pair  with  individuals  of  their  own 
race.  The  former,  of  Semitic  and  especially  of  Syrian-Arabian 
descent,  and  the  latter  of  Aryan  origin,  are  on  account  of  their 
migrations  and  their  historically  well-known  resistibility  con- 
sidered as  true  types  of  cosmopolitans.  The  Jews  have  a  certain 
homogeneity  with  the  Arabs,  Moors,  and  the  old  Phoenicians, 
and  have  gradually  advanced  towards  the  Mediterranean 
Sea  ever  since  they  became  dispersed  after  the  destruction 
of  the  Syrian  empires.  They  subsequently  spread  further 
North  and  West  into  colder  regions  where  they  became 
acclimatised;  this  acclimatisation  is  however  one  of  a  lighter 
kind  and  not  greater,  according  to  Bertillon,  than  that  of 
all  Aryan  nations. 

In  speaking  of  the  great  adaptability  of  the  Jews, 
one  is  really  bound  to  think  more  of  their  accommoda- 
tion to  the  political  and  social  circumstances  of  the 
countries  in  which  they  have  settled.  A  physical  accli- 
matisation to  bodily  exertions  such  as  are  required  f.  i. 
by  agricultural  pursuits,  they  had  no  need  to  undergo 
seeing  that  circumstances  necessitated  their  adoption  of 
other  vocations;  nor  have  the  Jews  either  formerly  or 
recently  attempted  to  settle  in  large  numbers  as  colonists 
in  tropical  countries.  Sporadic  Jewish  emigrants  have 
not  formed  there  any  Jewish  families  worth  speaking  of, 
as  either  they  or  their  descendants  have  departed  from 
the  tradition  of  the  Jewish  race  and  intermixed  with 
natives  of  their  adopted  countries. 

The  principal  European  emigrants  who  have  shown  them- 
selves particularly  suitable  for  acclimatisation  in  tropical 
regions  were  the  South  European  nations,  the  Spaniards,  Portu- 
guese, Maltese,  Italians  and  Levantines.  They  dwell  in  the 
countries  round  the  Mediterranean,  which,  to  begin  with, 
possess  an  average  temperature  by  14-18°  (C.)  higher;  theirs 
is  the  great  historical  high-way  which  migratory  nations  have 
traversed  from  time  immemorial,  perhaps  from  the  days  of  pre- 
historic man.  The  Iberian  nations  are  a  mixture  of  various 
acclimatisable  elements  which  stand  in  relationship  with  the 
Semitic  races  of  the  Arabs  and  Phoenicians.  The  other  nations 


148  HEALTH,  DISEASE,  MARRIAGE 

named  above  are  also  to  a  great  extent  mixed  products;  they 
all  have  a  dark  complexion  which  is  suitable  for  the  tropics.  The 
Italians  have  settled  in  the  countries  near  the  Red  Sea,  and  in 
North  and  South  America;  the  Portuguese  in  tropical  Africa, 
in  Southern  India  and  in  Brazil;  the  Spaniards  in  the  West- 
Indies,  in  Mexico,  on  the  large  South  American  continent,  in 
Peru,  Chili  and  the  Argentine  republic.  The  white  Spanish 
population  of  Cuba  which  amounted  in  1775  to  96,440  indi- 
viduals grew  so  that  in  1861  it  consisted  of  793,484  inhabitants, 
though  it  must  be  admitted  that  a  large  part  of  the  addition  is 
due  to  new  immigrants  and  race-mixture.  But  the  emigrants 
of  these  South  European  nations  have  not  remained  pure,  they 
have  mixed  with  the  natives  to  a  large  extent,  so  that  the  popu- 
lations which  claim  to-day  to  be  legitimate  Cubans,  Mexicans, 
Venezuelans,  Brazilians,  Chilians,  Peruvians,  etc.  are  in  reality 
mixed  products  of  Spanish  and  Portuguese  descent. 

The  two  principal  maritime  nations  of  Germanic  blood,  the 
English  and  the  Dutch  have  become  firmly  established  in  tropical 
India  and  the  Sunda  Islands,  but  they  have  treated  these  regions 
more  from  the  point  of  view  of  productive  colonies  than  as  an 
oversea  outlet  for  their  European  over-populations.  Many 
Englishmen  and  Dutchmen  have  emigrated  to  the  colonial 
possessions  of  their  respective  countries,  but  have  only  excep- 
tionally founded  there  permanent  families;  as  a  rule  they 
remained  either  alone  or  with  their  families  for  some  more  or 
less  prolonged  period  after  which  they  returned  to  Europe. 

In  the  French  colonies  situated  in  the  tropics  there  have  also 
been  no  permanent  populations  formed  which  are  of  pure 
French  blood.  The  emigrants  have  either  intermixed  with 
other  races  and  nations  or  returned  home.  It  is  therefore 
impossible  with  respect  to  the  French  also  to  say  definitely 
whether  they  possess  on  the  whole  an  adaptability  for  accli- 
matisation in  the  tropics. 

Since  the  year  1830  the  colonisation  of  Algeria  has 
been  attempted,  at  first  with  unfavourable  results,  but 
more  successfully  during  the  last  few  decades.  Accord- 
ing to  Bertillon  the  circumstances  in  Algeria  during 
1855-1856  were  as  follows: 


CLIMATE,  RACE  AND  NATIONALITY       149 

Difference  in  births 

+  16 

+  14 


Births 

Deaths 

Spaniards 

46 

30 

Maltese 

44 

30 

Italians 

59 

48 

French 

4i 

43 

Germans 

3i 

56 

—    2 
—25 

It  would  therefore  appear  that  the  Spaniards  and 
Italians  were  in  the  most  favourable  position,  and  that 
these  two  nations  are  capable  of  permanent  colonisation 
without  the  necessity  of  bringing  fresh  elements  from 
the  mother-country.  The  French  showed  if  no  great 
mortality  at  least  a  very  limited  number  of  births,  and 
the  Germans  a  high  mortality.  The  conditions  have  in 
spite  of  improvements  remained  practically  the  same  at 
the  present  day  ;  the  purely  French  element,  particularly 
that  part  of  it  coming  from  the  South  of  France  has 
become  acclimatised.  Those  who  thrive  best  in  Algeria 
to-day  are  Frenchmen  from  the  South  of  France, 
Spaniards,  Italians,  and  above  all,  Jews;  among  the 
latter  there  were  in  the  last  decade  55  births  to  about 
28  deaths.  The  German  colony  (Alsace-Lorrainers)  is 
as  before  still  in  a  bad  way;  it  shows  the  largest  mor- 
tality, formerly  55  and  now  39  deaths  per  1000  inhabi- 
tants, against  32  births. 

The  Germans  have  up  to  recently  had  no  proper  oppor- 
tunity of  showing  whether  they  possess  as  a  race  any  fitness  for 
acclimatisation  in  tropical  countries.  An  early  attempt  in  Brazil 
has  proved  futile,  since  when  D.  Pedro  in  1831  abdicated  the 
Brazilian  throne,  two  battalions  of  German  troops  were  com- 
pensated after  their  disbandment  by  a  grant  of  large  tracts  of 
country  between  Pernambuco  and  Utinas.  In  spite  of  all  possible 
assistance  from  the  Brazilian  government  the  whole  number  of 
them  died  within  one  year  from  the  effects  of  the  injurious 
emanations  from  the  soil  to  which  they  were  subjected  as  agri- 
culturists. (Helfft.) 

Mixture  of  races.  —  We  see  that  wherever  colonising 
enterprises  on  the  part  of  white  people  have  taken  place,  numer- 


150  HEALTH,  DISEASE,  MARRIAGE 

ous  mixtures  with  the  natives  or  other  coloured  races  have 
been  the  results.  Neither  in  East-India,  nor  in  the  West- 
Indies,  nor  in  Cuba,  Porto  Rico  or  Brazil,  have  the  families 
of  the  original  European  settlers  remained  unmixed  beyond 
the  third  or  fourth  generation.  But  the  greatest  vitality 
has  been  exhibited  by  the  numerous  cross-products  resulting  in 
the  tropics  from  the  mixture  between  Northern  immigrants  and 
native  women.  The  English  who  have  intermixed  with  the  latter 
less  than  others  have  therefore  obtained  the  least  success  as 
colonisers,  though  their  commercial  relations  would  seem  to 
point  them  out  as  the  most  suitable  for  the  purpose. 

Many  endeavours  have  been  made  to  find  out 
whether  there  are,  after  all,  any  cases  in  the  tropics,  of 
European  tribes  which  have  remained  pure  through 
several  generations.  Statistics  are  unfortunately  not 
available  as  they  are  either  absent  altogether  or  utterly 
unreliable.  We  are  dependent  entirely  on  individual 
traditions  and  moreover  great  mistakes  are  apt  to  occur 
when  considering  whether  a  racial  acclimatisation  has 
taken  place.  The  European  mixed-breeds  regard  them- 
selves according  to  the  demands  of  political  or  social 
necessities  sometimes  as  natives  and  sometimes  as  for- 
eigners. In  India  cross-breeds  are  frequently  called 
Europeans.  Travellers  who  have  reported  on  the  sub- 
ject have  for  these  reasons  frequently  been  misled  into 
wrong  calculations. 

It  is  reported  that  in  Reunion  a  French  colony  exists 
under  the  name  of  "Petit-Blancs"  whose  ancestors  immi- 
grated after  the  occupation  of  the  island  under 
Louis  XIV,  about  1650,  and  who  have  reproduced 
themselves  without  intermixture.  Individually  they  have 
become  quite  acclimatised,  they  pursue  hunting  and 
agriculture,  are  rustic  inhabitants,  and  though  poor  they 
are  bodily  in  the  best  condition.  The  town-dwellers,  on 
the  other  hand,  who  are  descendants  of  the  well-to-do 
portion  of  later  French  emigrants  show  a  high  mor- 
tality.— Rousselet  found  in  1867  in  Central  India 
(Bhopal)  in  the  heart  of  the  Windhya  mountains  a 


CLIMATE,  RACE  AND  NATIONALITY       151 

small  tribe  of  European  descent  which  may  be  traced  to 
a  French  immigration  that  took  place  in  1557,  and 
which  has  retained  the  European  character  of  the  colony 
by  avoiding  inter-mixture  with  other  than  European 
nations,  especially  Portuguese. 

The  Spanish  tobacco-peasants  in  Cuba  are  said  to  have 
prospered  so  markedly  that  their  number  of  95,440  in 
1774  went  up  to  793,884  in  1861,  and  that  their  mor- 
tality was  lower  than  that  of  the  mother-country. 

There  are  said  to  be  six  families  in  Peru  which  have 
kept  themselves  pure  for  200  years. 

Stokvis  particularly  has  taken  great  pains  in  estab- 
lishing the  pedigrees  of  pure  European  families  in  the 
tropics,  and  gives  a  few  examples  from  Surinam.  Cap- 
tain Schultze  has  given  a  minute  description  of  the 
genealogical  tree  of  a  Dutch  family  in  Java  recording 
its  history  for  more  than  100  years. 

Stokvis  mentions  also  the  population  of  the  very 
small  island  of  Kicser  in  the  Malay  Archipelago  which 
includes  European  inhabitants  who  claim  descent  from 
Dutch  soldiers  that  had  remained  there  150  years  ago 
after  the  destruction  of  the  fortress  and  married  Euro- 
pean women.  But  as  Kicser  is  frequently  visited  by 
sailing  vessels  the  crews  of  which  generally  stay  there 
for  some  time,  it  is  doubtful  whether  the  inhabitants 
have  not  occasionally  received  an  addition  of  fresh 
blood.  (Daubler.} 

A  careful  examination  of  family  registers  for  which  abso- 
lute purity  was  claimed  has  in  the  cases  where  such  an  examina- 
tion was  possible  proved  that  intermixture  with  foreign  blood 
has  taken  place  or  that  such  blood  was  introduced  by  some  lateral 
chain  that  could  not  be  followed  up. 

The  Spanish  and  Portuguese  immigrants  to  the  tropical 
countries  of  the  West-Indies,  Cuba,  Ecuador,  Brazil,  and 
Mexico  whose  families  have  become  the  present-day  inhabitants 
and  are  proud  that  their  blood  is  of  the  purest  possible,  can- 
not, judging  from  the  ordinary  course  of  circumstances  be 
looked  upon  otherwise  than  that  intermixture  has  played  a  part 


152  HEALTH,  DISEASE,  MARRIAGE 

in  their  family  histories.  The  Iberian  nations  have  always 
shown  an  inclination  to  mix  their  blood  with  that  of  the  nations 
among  whom  they  dwelt.  Even  in  their  physiognomy  these 
people  have  changed  so  much  that  they  do  not  in  the  least 
resemble  any  longer  their  European  ancestors.  Spaniards  and 
Portuguese  have  in  spite  of  the  great  resistibility  which  they 
are  said  to  possess  against  tropical  influences  remained  only 
relatively  pure  in  Porto  Rico;  they  avoid  every  kind  of  fatiguing 
work.  The  older  white  population  has  almost  entirely  mixed 
with  Arab,  Indian  and  Negro  blood  as  well  as  that  of  Mestees. 
Whether  pure  racial  propagation  in  the  tropics  is  at  all 
possible  cannot  under  present  circumstances  be  said.  A  Euro- 
pean colonisation  which  has  remained  incontestably  pure 
through  several  generations  without  any  admixture  from  outside 
has  never  been  undertaken  systematically;  it  is  therefore  impos- 
sible to  say  whether  such  an  experiment  could  or  would  succeed. 
Natural  conditions  seem  to  show  that  accommodation  takes 
place  differently.  Stokvis  thinks  that  not  only  is  an  European 
acclimatisation  possible,  but  also  complete  colonisation.  The 
latter  however  never  takes  place  in  reality  in  a  pure  form.  Even 
the  Boers  to  whom  he  refers  and  who  are  regarded  as  suitable 
for  the  tropics  are  fond  of  staying  in  the  tropical  highlands  and 
frequently  return  to  the  Transvaal. 

The  successful  colonisation  in  the  South  and  West 
of  Africa  by  the  English  and  Dutch,  in  the  Argentines 
and  in  Chili  etc.  by  Spaniards,  in  the  Southern  States 
of  Brazil  (Santa  Catharina,  Rio  Grande)  on  the  Rio 
de  la  Plata  estuary,  and  in  Queensland  by  Germans, 
does  not  come  here  into  consideration,  for  these  are 
places  situated  in  the  temperate  zone  the  climate  of  which 
resembles  that  of  the  respective  European  home-coun- 
tries and  which  present  in  some  respects  considerable 
advantages. 

The  pairing  of  the  Europeans  settled  in  the  tropics  with 
native  women  is  a  necessary  means  of  naturalisation,  if  it  is 
only  for  the  reason  that  white  women  decline  and  grow  old  far 
too  soon.  But  there  are  European  women  accustomed  to  the 
tropics  from  whose  union  with  natives  a  strong  progeny  has 


153 

resulted.  The  propagation  of  the  white  race  is  dependent  on 
an  addition  of  foreign  blood,  even  if  it  emanates  from  coloured 
or  mixed  races;  thus  .the  offspring  of  Europeans  in  the  tropics 
retain  their  vitality  and  acquire  finally  definite  types. 

Pairing  with  native  races  is  particularly  beneficial  in  facili- 
tating the  acclimatisation  of  the  white  race.  By  such  means 
qualities  are  formed  which  render  the  sojourn  of  Europeans  in 
foreign  climes  endurable.  "In  this  way  the  race  changes  to  a 
severer  extent  than  by  Darwin's  'Selection'  or  other  influences" 
(Firchow) . 

ILndemic  diseases. — It  is  finally  necessary  to  mention 
the  endemic  diseases  which  influence  the  process  of  acclimatisa- 
tion to  an  enormous  extent,  and  which  form  the  principal 
factors  upon  the  basis  of  which  the  question  of  the  possibility 
of  complete  European  adaptation  in  the  tropics  has  been  judged. 
Although  such  a  possibility  has  been  admitted  by  some  with 
regard  to  a  physiological  accommodation  to  the  climate,  the 
greatest  doubts  have  arisen  as  to  whether  it  is  possible  to 
overcome  the  pathological  conditions,  and  even  if  such  a  suc- 
cessful result  could  be  obtained  in  the  case  of  single  individuals 
it  can  hardly  be  expected  in  an  entire  colony  or  in  a  large  num- 
ber of  people.  Some  observers,  in  fact,  relying  upon  existing 
data  have  absolutely  denied  the  possibility  of  adaptation  to 
the  pathological  difficulties  of  the  climate. 

As  an  illustration  we  give  here  the  following  figures 
relating  to  the  military  population  of  the  Dutch  Indies 
consisting  of  12,974  Europeans  and  15,521  natives,  for 
the  year  1874  (according  to  Uffelmann)  : 

Per  1000    Europeans  Per  1000  Natives 

Diseased        Dead  Diseased  Dead 

Malaria  747-9        I5-°  362.3  3.6 

24.8  3.8 

23-5  8.3 

1.7  0.38 

0.51  0.33 

35-4  1-35 

In  Finschhafen  (German  New  Guinea)  there  were 


Dysentery 

106.8 

23.1 

Cholera 

62.7 

32-5 

Hepatitis 

21.7 

I-I5 

Enteric  fever 

IO.O 

0.38 

Beri-beri 

2.2 

0.38 

154  HEALTH,  DISEASE,  MARRIAGE 

according  to  Schellong  in  1886-1888  no  less  than  99% 
of  the  Europeans  living  there  suffering  from  malaria; 
about  50%  of  all  Europeans  and  Malays  were  ill  with 
malaria  every  month,  and  those  who  had  to  stay  for 
1 6   months  were  faced  with  the  prospect  of  having 
malaria  6  times.     The  mortality  of  Europeans  from 
malaria  was  90  per  thousand,  that  of  the  Malays  o. 
As  we  shall  see  from  the  following  remarks  considerable 
progress  has  been  made  in  these  respects  during  the  last  two 
decades.    This  applies  especially  to  malaria  which  has  always 
been  one  of  the  principal  factors  in  connection  with  acclimatisa- 
tion. 

Malaria. — From  the  earliest  times  of  historical  medicine 
malaria  has  been  known  and  always  associated  with  the  influence 
of  the  soil.1  The  necessity  of  establishing  human  habitations  in 
the  neighbourhood  of  water  supplies,  either  the  sea  or  rivers, 
brought  with  it  the  constant  struggle  against  malaria,  the  cause 
of  which  was  up  to  a  few  years  ago  supposed  to  lie  in  a  miasma 
emanating  from  the  soil. 

As  a  result  of  the  ubiquity  of  malaria  just  in  those  tropical 
regions  which  are  the  first  goal  of  colonists,  the  opinion  became 
universal  that  the  ability  of  Europeans  to  become  acclimatised 
in  the  tropics  is  synonymous  with  their  ability  to  become  accli- 
matised against  malaria,  and  that  the  process  of  adaptation  is 
completed  when  the  persons  otherwise  acclimatised  are  capable 
of  cultivating  by  themselves  the  ground  which  nourishes  them. 
The  dangers  of  malaria  do  not  lie  only  in  the  injury  to  health 
or  in  the  frequent  relapses  which  lead  to  severe  anaemias  and 
cachectic  conditions  often  ending  with  death,  but  also  in  the 
circumstance  that  two  of  the  most  frequent  consequences  of  the 
disease  are  sterility  in  females  and  an  enormous  infantile  mor- 
tality. For  these  reasons  the  foundation  and  growth  of  families 
are  so  difficult. 

The  only  remedy  to  counteract  the  evil  influences  of  malaria 


*)  S.  Reinhold  Rage's  Bearbeitung  der  Malaria  im  Handbuch 
der  pathogenen  Mikroorganismen  von  Kolle  und  Wassermann,  Bd.  I. 

English  Translation  by  Eden  Paul,  M.D.  (Rebman  Company,  New  York 
and  London.) 


CLIMATE,  RACE  AND  NATIONALITY       155 

is  supposed  to  lie  in  the  cultivation  of  the  soil  and  especially  in 
its  drainage,  but  this  can  only  be  accomplished  by  sacrifices, 
personal  risk  or  the  hands  of  coloured  labourers,  Negroes  or 
Malays,  who  are  known  to  possess  a  certain  immunity  against 
the  disease.  But  as  it  is  hardly  possible  to  anticipate  that  the 
tropics  will  in  this  respect  become  so  changed  as  to  present  no 
dangers  to  Europeans  arriving  there,  former  observers  have 
all  expressed  the  opinion  that  an  acclimatisation  against  malaria 
does  not  exist  and  never  will.  Virchow  pointed  out  that  the 
sanitary  measures  adopted  in  the  Roman  Campagna,  though 
carried  out  under  circumstances  vastly  superior  to  those  in  the 
tropics,  were  nevertheless  failures.  But  what  a  change  has 
taken  place  since !  In  that  fever-stricken  locality  Ostia,  one 
of  the  worst  of  its  kind  in  the  Campagna  where  no  one  ever  ven- 
tured to  remain  for  a  few  hours  after  dark  three  English  investi- 
gators, Sambon,  Low  and  Rees  have  in  1900  spent  several 
months  without  being  attacked  by  malaria  either  at  the  time 
or  subsequently,  thus  proving  the  correctness  of  the  modern 
view  and  the  reliability  of  the  prophylactic  measures  resulting 
from  it. 

By  the  very  important  researches  of  Laveran,  Golgi,  Ross, 
Koch,  and  many  others,  the  malarial  parasites  and  their 
developmental  phases  as  well  as  the  part  played  by  the  mos- 
quito have  been  established  in  a  most  convincing  manner.  The 
malaria-mosquito  theory  explains  clearly  the  relations  between 
the  disease  on  the  one  hand  and  age,  sex,  employment  and 
race  on  the  other,  whereas  formerly  everything  was  mixed  up 
in  the  idea  of  acclimatisation. 

Children  and  young  persons  to  the  age  of  about  35  form 
the  majority  of  sufferers  from  malaria ;  the  first  years  of  child- 
life  show  the  greatest  predisposition  to  it.  Sex  does  not  appear 
to  play  any  important  part,  and  if  women  are  generally  less 
liable  to  attack  it  is  because  their  domestic  duties  prevent  them 
from  being  out  in  the  open  as  much  as  men,  thus  reducing  their 
exposure  to  risk.  Pregnant  women  are  not  immune,  as  it  was 
formerly  believed,  and  child-bed  is  even  a  predisposing  factor. 
The  explanation  is  simply  that  infected  mosquitoes  are  attracted 
under  such  circumstances. 


156  HEALTH,  DISEASE,  MARRIAGE 

Though  no  race  or  nationality  is  exempt  from  malaria,  the 
peoples  descending  from  the  Caucasian  race  (Europeans, 
Arabs  from  the  Berber  States,  Hindus)  show,  according  to 
Hirsch,  the  greatest  predisposition,  and  namely  in  the  sense 
that  an  attack  of  the  disease  predisposes  as  a  rule  to  further 
attacks;  the  Malay  and  Mongolian  tribes  have  a  somewhat 
lesser  predisposition,  and  least  of  all  the  Ethiopian  race;  indi- 
viduals belonging  to  the  latter  do  suffer  from  malaria,  but 
only  seldom  and  then  in  a  mild  form. 

R.  Koch  has  explained  how  immunity  is  acquired  by  the 
natives;  he  found  that  adult  natives  in  malarial  countries  are 
free  from  the  disease,  whereas  the  children  suffer  most  terribly 
up  to  1 00%.  If  they  recover  they  gradually  acquire  by  fresh 
attacks  or  relapses  a  definite  immunity.  The  number  of  chil- 
dren infected  with  malaria  diminishes  as  age  advances;  at  the 
age  of  10  there  is  generally  found  as  a  last  sign  of  former 
malaria  an  enlarged  spleen,  which  also  disappears  towards 
puberty,  so  that  the  adult  native  appears  finally  as  a  healthy  indi- 
vidual immune  against  malaria. 

If  we  wish  therefore  to  be  informed  how  and  to  what 
extent  a  certain  locality  is  subjected  to  malaria  we  must  examine 
not  only  the  adults,  but  the  children  as  well,  and  particularly 
the  very  youngest  among  them.  Where  the  latter  are  affected 
malaria  is  endemic  and  one  must  be  prepared  for  the  outbreak 
of  an  epidemic  should  circumstances  favour  the  development 
of  the  malarial  parasites.  Koch  has  also  demonstrated  that 
immunity  against  one  form  of  malaria  f.  i.  the  tertian, 
does  not  protect  against  other  forms  such  as  the  quartan  or 
tropical. 

Thanks  to  the  improved  knowledge  of  the  cause  and  dis- 
tribution of  malaria,  and  to  the  perfected  methods  of  examina- 
tion of  the  blood  we  are  to-day  in  a  position  to  take  precautions 
with  a  definite  object  in  view,  and  by  adopting  Koch's  advice 
to  undertake  the  stamping-out  of  malaria. 

The  personal  prophylaxis  consists  in  the  administration  of 
I  gramme  of  quinine,  according  to  Koch's  method,  every  loth 
or  nth  day,  for  the  purpose  of  destroying  the  parasites  cir- 
culating in  the  blood;  embrocation  with  ethereal  oils  and  the 


CLIMATE,  RACE  AND  NATIONALITY       157 

use  of  mosquito-nets  or  curtains  are  of  value  as  protectors 
against  the  parasite. 

The  general  phophylaxis  endeavours  to  prevent  infection 
by  destroying  the  mosquitoes.  It  has  been  proposed  to  pour 
petroleum  over  the  pools  in  which  the  anopheles  finds  a  breeding 
place,  and  then  to  kill  the  larvae.  But  this  practice  has  not 
proved  successful  for  various  reasons.  Similarly,  the  attempts 
to  drain  the  marshy  districts  have  fared  no  better.  The  idea 
is  theoretically  correct  but  on  account  of  the  great  expense  it 
entails,  capable  of  being  carried  out  in  small  localities  only. 
Where  anopheles-containing  pools  can  be  easily  drained,  this 
must  be  done,  of  course,  but  it  is  necessary  to  remember  that 
the  process  must  be  repeated  regularly  and  most  scrupulously, 
otherwise  the  result  obtained  will  be  of  little  value. 

Opposed  to  these  measures,  is  the  proposal  of  Koch  to 
exterminate  the  malarial  parasites,  and  for  this  purpose  it  is 
necessary  to  find  out  not  only  the  severe  cases  but  also  the  very 
mild  ones  which  hardly  ever  come  under  the  notice  of  the 
medical  practitioner.  This  can  be  done  by  means  of  the  exami- 
nation of  the  blood.  By  following  this  method  Koch  succeeded 
in  a  short  time  in  rendering  Stephansort  (New  Guinea)  per- 
fectly free  from  malaria.  But  as  the  circumstances  are  not 
everywhere  so  favourable  as  in  Stephansort  it  is  hardly  to  be 
expected  that  the  results  will  always  be  the  same,  but  reports 
from  other  places  seem  to  offer  every  encouragement.  On  the 
other  hand  Plehn1  points  out  that  Koch's  proposal  is  not  free 
from  disadvantages.  In  large  localities  it  is  practically  impos- 
sible to  find  out  and  examine  all  the  inhabitants;  the  physical 
exertion  of  a  small  number  of  medical  men  such  as  can  be 
obtained  in  the  tropics  would  hardly  be  equal  to  the  task;  and 
the  constant  coming  and  going  of  the  ordinary  traffic  would 
certainly  prove  an  insuperable  obstacle.  The  process  recom- 
mended by  Koch  would  moreover  arrest  the  natural  immunisa- 
tion which  goes  on  in  native  children,  and  this  would  result  in 
their  being  attacked  by  the  disease  later  in  life  when  they 
have  changed  their  habitation.  It  would  in  fact  mean  injury 


Archiv.  fur  Schiffs-  und  Tropenhygiene  1901. 


i58  HEALTH,  DISEASE,  MARRIAGE 

to  a  large  number  of  natives  in  order  to  protect  a  small  number 
of  immigrants. 

Yellow  fever. — A  more  limited  significance  than 
malaria  is  possessed  by  yellow  fever,  a  disease  associated 
entirely  with  tropical  and  sub-tropical  conditions  and  one 
which  spreads  only  under  special  climatic  circumstances.  As 
permanent  foci  may  be  regarded  the  Antilles  and  Mexico 
which  are  generally  supposed  to  represent  the  cradle  of  yellow 
fever;  from  there  the  African  coast  from  the  mouth  of  the 
Senegal  to  the  5th  degree  of  northern  latitude  became  infected 
with  Sierra  Leone  as  the  principal  centre;  this  was  also  the 
case  with  the  Brazilian  coast,  especially  the  ports  of  Rio  de 
Janeiro  and  Santos,  which  are  at  the  present  day  suffering 
from  a  permanent  epidemic. 

Yellow  fever  attacks  with  predilection  the  white  race;  the 
yellow  race  is  affected  to  a  much  smaller  extent,  and  the  negroes 
are  practically  absolutely  immune  against  it.  Mulattoes  show 
little  predisposition  but  not  the  immunity  possessed  by  the  pure 
African  race. 

It  appears  that  the  susceptibility  to  yellow  fever  stands  in 
inverse  ratio  to  the  average  temperature  of  the  zone  from  which 
the  individual  springs.  Griesinger  has  pointed  this  out  with 
reference  to  Europeans  by  showing  that  Norwegians,  Russians, 
Germans  and  Dutchmen  are  far  more  liable  to  be  attacked 
than  Frenchmen,  Spaniards,  Italians  and  Portuguese.  The 
same  thing  has  been  demonstrated  in  America.  North-Ameri- 
cans, Argentinians,  Uruguayans,  and  Chilians  are  far  more 
susceptible  than  Brazilians,  Mexicans,  Peruvians  and  Bolivians. 
Negroes,  though  immune  against  yellow  fever,  become  suscep- 
tible to  it  or  lose  their  immunity  if  they  are  born  in  colder 
zones  or  stay  there  for  some  years. 

The  susceptibility  of  white  immigrants  into  yellow  fever 
zones  diminishes  while  they  remain  there.  Acclimatisation  has 
always  played  an  important  part  in  the  estimation  of  the  danger 
threatened  from  yellow  fever.  According  to  an  old  doctrine,  it 
was  assumed  that  a  stay  of  5  years  in  a  yellow  fever  district 
was  sufficient  to  impart  such  immunity  as  is  possessed  by  native 
children  in  their  5th  year  of  age,  and  this  appears  to  agree 


CLIMATE,  RACE  AND  NATIONALITY       159 

with  the  facts.  An  interruption  in  the  sojourn  annuls  the 
immunity  obtained,  and  the  latter  can  moreover  be  acquired 
only  where  yellow  fever  is  prevalent,  and  not  at  a  greater  or 
lesser  distance.  Thus  f.  i.  the  permanent  inhabitants  of  Rio 
de  Janeiro  are  immune,  but  not  so  Brazilians  coming  from  other 
parts  of  the  country.  Men  and  women  are  equally  liable  to 
be  attacked,  women  perhaps  slightly  less  because  they  are  less 
exposed  to  infection.  Among  immigrants,  there  are  generally 
more  male  sufferers  than  female. 

During  pregnancy,  child-bed  and  lactation,  non-acclimatised 
women  have  a  greater  predisposition  to  the  disease. 

The  mystery  surrounding  the  cause  of  yellow  fever  has  also 
been  cleared  up  recently  with  a  probability  amounting  almost 
to  certainty.1  After  several  unsuccessful  attempts  to  find  the 
specific  schizomycetse,  a  North  American  expedition  sent  out 
to  Cuba  in  1900  to  study  the  cause  of  yellow  fever  and  having 
at  its  head  Reed,  Carroll,  Agramonte  and  Lazear,  was  for- 
tunate in  discovering  that  it  is  possible  to  transmit  the  disease 
by  a  prick  from  a  mosquito  infected  with  yellow  fever.  The 
kind  of  mosquito  coming  in  question  is  the  stegomyia  fasciata 
Theobald;  a  kind  of  culex  present  in  well-known  yellow  fever 
localities.  But  the  real  organic  cause  of  the  disease  is  unfor- 
tunately not  yet  known.  For  practical  purposes,  however, 
much  is  gained  by  the  discovery  that  mosquitoes  act  as  hosts 
and  transmitters  of  the  disease-poison.  The  precautionary  meas- 
ures indicated  are  no  longer  vague  and  of  a  general  hygienic 
nature,  but  consist  in  endeavours  to  prevent  mosquital  inocu- 
lations. The  prophylaxis  is  therefore  similar  to  that  relating  to 
malaria,  only  comparatively  more  simple.  Much  has  already 
been  done,  and  successfully  as  far  as  it  is  possible  to  judge,  in 
fighting  yellow  fever  in  Havana  in  the  manner  mentioned. 

In  1901,  all  the  cases  reported  were  isolated,  pro- 
tected against  mosquito-bites,  and  their  surroundings 
disinfected;  26,000  breeding-places  of  mosquitoes  were 
looked  up  and  destroyed.  In  October,  generally  the 
worst  month,  there  was  not  a  single  death  or  illness, 
as  against  308  cases  of  illness  and  174  deaths  from 


'For  details  see  my  article  in  the  Berl.  Klin.  Woch.  1903.  31-32- 


160  HEALTH,  DISEASE,  MARRIAGE 

yellow  fever  in  the  preceding  year;  the  returns  for  1902 
are  equally  satisfactory. 

Judging  by  analogy  from  what  has  been  said  with  reference 
to  malaria,  immunity  against  yellow  fever  is  probably  acquired 
through  repeated  bites  from  infected  mosquitoes  which  produce 
mild  forms  of  the  disease  that  escape  observation.  We  may  say 
that  the  mosquito-theory  of  yellow  fever  explains  the  whole 
epidemiology  of  this  disease  in  a  simple  and  natural  manner 
and  that  we  are  at  present  in  a  position  to  account  for  its 
method  of  dissemination,  its  predilection  for  certain  places  and 
its  absence  from  others.  We  can  also  understand  now  why — 
and  this  is  a  fact  which  has  been  known  for  more  than  a  cen- 
tury— elevated  places  in  yellow  fever  districts  are  free  from 
the  disease  in  spite  of  the  frequent  contact  of  persons  and 
objects  with  infected  centres.  All  these  phenomena  are  con- 
nected with  the  stegomyia  f asciata  and  its  mode  of  life ;  where- 
ever  this  insect  can  fly  and  remain  yellow  fever  will  under 
circumstances  spread. 

Cholera. — With  regard  to  the  two  most  dreaded  infec- 
tious diseases,  cholera  and  plague,  it  has  also  been  possible 
since  their  respective  causative  agents  have  been  recognised,  to 
gain  points  of  view  which  are  practically  important  for  pur- 
poses of  prophylaxis.  Cholera  and  plague  deserve  mention 
here  as  they  are  in  the  tropics  endemic  diseases;  they  have 
repeatedly  assumed  the  form  of  violent  epidemics  affecting 
regions  far  beyond  their  centres,  and  even  that  of 
pandemics. 

Cholera  is  for  the  whole  world  with  the  exception  of  the 
Ganges  Valley  an  imported  disease  which  has  made  the  tour 
of  the  globe  in  5  great  pandemics.  The  infection  takes  place, 
as  proved  so  convincingly  by  Koch  and  his  school,  by  means  of 
infected  water,  coming  from  rivers,  wells  or  other  similar 
sources,  occasionally  through  infected  articles  of  food,  milk, 
etc.  if  these  have  in  any  way  come  in  contact  with  the  infected 
water.  The  isolation-measures  formerly  in  use  have  shown 
themselves  ineffective  in  arresting  the  disease  because  those 
who  suffer  from  cholera  obviously  and  seriously  do  not  as  a 
rule  travel,  and  mild  cases  which  are  just  as  infective  are  not 


recognisable.  On  the  other  hand,  the  precautionary  remedies 
suggested  by  Koch's  theory  and  consisting  of  a  good  water- 
supply,  reliable  sewerage,  isolation  of  the  first  patient  observed 
and  of  those  infected  by  him,  thorough  disinfection  of  the  dis- 
charges and  all  objects  coming  in  contact  with  them,  have 
proved  of  benefit  as  prophylactics.  Gastric  and  intestinal  affec- 
tions, even  simple  errors  in  diet,  increase  the  individual  pre- 
disposition; experience  has  shown  that  men,  women  and  chil- 
dren are  equally  affected,  and  that  puerperal  women  are  more 
liable  to  be  attacked. 

Plague. — The  specific  bacillus  of  plague,  discovered  by 
Yersin  and  Kitasato  has  the  peculiar  property  that  it  is  very 
easily  conveyed  to  rats  and  mice  and  that  these  animals  as  well 
as  infected  human  beings,  who  are  apparently  in  good  health 
though  harbouring  the  plague-bacilli,  can  import  the  disease 
and  disseminate  it.  The  infection  takes  place  through  abrasions 
in  the  skin  and  the  entrance  of  the  bacilli,  in  pulmonary  plague 
through  inspiration  of  the  same;  it  is  questionable  whether  the 
infection  can  also  take  place  through  the  medium  of  food  and 
drink.  With  regard  to  plague  also  the  susceptibility  of  the 
sexes  is  alike. 

If  we  consider  the  progress  made  in  the  recognition  of  the 
cause  of  these  diseases  and  in  the  knowledge  of  the  means  by 
which  to  combat  and  to  avoid  them,  we  may  fairly  say  that 
they  no  longer  constitute  any  obstacles  against  the  acclimatisa- 
tion of  European  colonists.  On  the  contrary!  The  latter  have 
thanks  to  their  social  education  certain  advantages  over  the 
natives  who  also  have  no  natural  immunity  against  these  dis- 
eases, even  where  they  are  endemic.  Cholera  is  perennial  among 
the  inhabitants  of  the  Ganges-delta,  and  as  regards  plague  it 
has  been  noticed  that  Negroes  are  more  liable  to  attack  than 
others,  after  them  come  the  Berbers  and  Nubians,  and  in  the 
third  place  the  Arabs;  Europeans  are  most  favourably  situated 
in  this  respect  and  from  among  them  the  Northerners  are  more 
protected  than  the  Southerners  such  as  Turks,  Greeks  and 
Armenians.  The  Parsees  are  said  to  possess  a  certain  natural 
immunity.  The  Chinese  however  who  are  otherwise  particu- 
larly suited  for  colonisation  purposes  are  also  subject  to  the 


1 62  HEALTH,  DISEASE,  MARRIAGE 

influences  of  the  endemic  diseases.  According  to  Hirsch,  pre- 
disposition plays  here  a  less  important  part  than  social  con- 
siderations ;  superior  hygienic  conditions  seem  to  have  a  greater 
significance  in  regard  to  predisposition  than  membership  of 
some  definite  race. 

Protective  inoculation. — We  have  already  seen 
how  the  immunity  against  malaria  formerly  believed  to  be 
attached  to  the  negro  race  is  produced  by  the  endurance  of  the 
disease  at  an  early  age.  Exceptionally  there  may  be  occasion- 
ally noticed  a  natural  immunity  against  cholera  and  plague 
also,  arisen  individually  and  spontaneously;  experience  however 
teaches  that  such  immunity  can  only  be  acquired  through  over- 
coming an  attack  of  the  respective  infection,  and  it  is  upon 
the  basis  of  this  process  that  endeavours  have  been  made  to 
protect  individuals  by  inoculation  against  cholera  and  plague. 
Though  partisan  hatred  and  favour  may  incline  one  way  or  the 
other,  practical  successes  cannot  be  denied;  the  inoculations 
have  in  any  case  for  emigrants  to  dangerous  localities  at  least 
the  meaning  of  important  precautions. 

An  example  of  successful  inoculation  we  have  in  vaccination 
which  has  resulted  in  rendering  small-pox  as  no  longer  a  dan- 
gerous element  in  regard  to  the  settlement  of  Europeans  any- 
where. Those  who  are  opposed  to  vaccination,  and  there  are 
hardly  any  among  them  who  are  scientifically  trained  medical 
men,  should  see  the  striking  difference  in  countries  where  small- 
pox is  prevalent  between  the  vaccinated  and  non-vaccinated 
without  distinction  of  race  and  social  position,  and  they  would 
soon  admit  their  error. 

Dysentery. — By  the  provision  of  a  good  water  supply 
it  would  be  possible  to  counteract  the  dangers  arising  from 
dysentery,  as  the  producers  of  this  disease,  the  special  bacilli 
and  amoeba*  are  generally  introduced  into  the  body  through 
the  agency  of  water.  The  dreaded  tropical  abscess  of  the  liver 
is  in  most  cases  also  a  consequence  of  amoebal  infection.  It  is 
superfluous  to  add  that  for  purposes  of  prophylaxis  against 
dysentery  improved  general  sanitation  and  careful  nutrition  are 
necessary  requirements;  suitable  arrangements  for  disposing 
of  the  foecal  discharges  generally,  and  in  cases  of  dysentery 


CLIMATE,  RACE  AND  NATIONALITY       163 

particularly,  are  essential  for  the  prevention  of  the  spread  of 
the  disease. 

Rational  nutrition  can  do  much  in  preventing  the  gastric 
and  intestinal  troubles  so  frequent  in  the  tropics,  as  well  as 
the  consequences  to  which  they  give  rise.  Diseases  of  the  liver 
are  not  so  common  as  it  is  generally  believed  and  are  not 
eo  ipso  a  result  of  the  climate. 

A  glance  at  the  pathological  dangers  of  the  tropical  climate 
reveals  the  fact  that  the  armamentarium  of  modern  hygiene  is 
able  to  cope  with  them,  and  that  they  are  not  permanent  but 
temporary  factors  which  oppose  acclimatisation.  With  the 
advance  in  general  civilisation  it  will  probably  be  possible  to 
overcome  all  endemic  diseases. 

Possibility  of  acclimatisation. — Only  as  far  back 
as  10  years  ago  the  opinions  whether  there  is  a  possibility  for 
the  white  race  to  become  acclimatised  in  the  tropics  were  sharply 
opposed  to  one  another;  the  number  and  reputation  of  those 
observers  who  denied  that  possibility  sufficed  to  render  their 
opinion  the  preponderating  one,  and  the  latter  received  addi- 
tional support  from  the  conviction  that  the  danger  of  malaria 
was  insurmountable.  As  adherents  of  this  opinion  we  find  most 
English  authors,  among  the  French,  Dutroulean,  Leroy  de 
Mericourt,  Jousset,  Fonsagrives,  Baudin,  and  others;  among 
Germans,  Helfft,  Mahly,  Rover,  Firchow,  Hirsch,  and  others. 
The  Dutch  author  Stokvis  was  an  absolute  optimist;  de  Quartre- 
fages,  Treille,  Bertillon,  Rochard  though  not  believers  in  the 
absolute  capability  of  Europeans  to  become  acclimatised  looked 
upon  the  same  with  rather  more  favour.  Unanimity  of  opinion 
on  this  important  question  has  not  been  obtained  as  yet,  but  the 
scientific  advances  recorded  above  have  resulted  in  creating  a 
different  point  of  view.  Hope  and  confidence  have  been  estab- 
lished that  the  difficulties  connected  with  acclimatisation  will  be 
overcome,  and  the  great  activity  displayed  by  scientists,  govern- 
ments and  associations  in  colonisation  efforts,  as  shown  f.  i.  in 
Germany,  France,  Holland  and  Italy,  is  proof  positive  that  the 
problem  is  seriously  being  dealt  with.  And  although  the  practi- 
cal results  obtained  so  far  are  not  so  considerable  as  one  would 
wish,  more  may  certainly  be  expected  and  looked  for.  The 


1 64  HEALTH,  DISEASE  MARRIAGE 

march  of  conquest  which  the  white  race  has  undertaken  in  the 
tropics  is  in  reality  an  attempt  to  better  the  economic  conditions 
of  humanity,  and  it  will  require  the  united  efforts  of  all  nations 
to  bring  it  to  a  successful  issue.  The  old  saying  "white  heads 
and  black  hands"  will  for  the  present  have  to  remain  in  force, 
and  the  Negroes,  the  Indians  and  the  Malays  will,  in  view  of 
the  fact  that  they  can  multiply  and  thrive  in  the  tropics  without 
the  assistance  of  other  races,  for  some  time  to  come  furnish  the 
requisite  manual  labour.  In  the  temperate  zones,  the  coloured 
races  are  inferior  to  the  whites  or  to  the  Aryan  mixed  races. 

Gradual  acclimatisation. — More  than  30  years  ago 
Quatrefages  made  the  suggestion  of  gradual  acclimatisation; 
i.e.  that  colonists  should  proceed  by  stages  from  station  to  station 
until  they  reached  the  insalubrious  districts.  Stokvis  has  recently 
asserted  that  Europeans  who  are  acclimatised  in  the  sub-tropics 
can  easily  adapt  themselves  to  the  tropics,  and  Felkin1  believes 
that  the  white  race  can  accommodate  itself  to  the  tropical  cli- 
mate provided  that  one  or  two  generations  show  first  their 
vitality  in  sub-tropical  regions. 

At  the  tropics  as  far  as  the  nth  degree  of  lat. 
the  humidity  of  the  atmosphere  and  the  heat  are  not 
so  great  as  in  the  real  equatorial  countries;  the  soil  is 
also  healthier;  then  there  is  the  differentiation  in  the 
seasons  which  gradually  disappears  the  nearer  we 
approach  to  the  equator,  so  that  in  the  countries  near 
the  latter  there  is  not  even  any  distinct  difference  between 
rainy  and  dry  periods.  It  is  this  circumstance  in  associa- 
tion with  the  humidity  of  the  soil  which  retains  the 
stagnant  moisture  and  the  greater  humidity  of  the  air 
that  act  injuriously  upon  the  physiological  functions  of 
the  whites.  For  these  reasons  the  idea  of  gradual  accli- 
matisation is  certainly  worthy  of  consideration. 
It  is  also  noteworthy  that  tropical  heights  of  1500-2000  m. 
are  climatically  equal  to  sub-tropical  districts. 

If  acclimatisation  in  the  tropics  is  to  be  possible,  it  is  essen- 
tial that  the  individuals  concerned  should  be  in  perfect  health 


*VIL     International  Congress  of  Hygiene. 


i65 

with  normal  hearts  and  undisturbed  digestive  functions.  As  to 
the  foundation  of  families  we  have  already  seen  what  advan- 
tages accrue  from  intermixture  with  indigenous  inhabitants 
or  with  such  races  which  become  acclimatised  with  greater 
ease.  An  occasional  return  to  places  in  the  temperate  zone  is 
of  great  value  to  the  individual  welfare,  and  equally  advan- 
tageous for  the  propagation  of  a  strong  and  healthy  progeny 
is  a  frequent  addition  of  fresh  European  blood  by  marriage 
with  newly-arrived  emigrants. 

Favoured  colonies. — The  European  emigrant  has 
mainly  made  his  way  to  such  tropical  countries  with  which 
the  mother-country  is  in  special  relations  either  as  former  or 
present  colonial  possessions,  or  on  account  of  the  commercial 
intercourse  or  community  of  language.  Hygienic  advantages 
or  disadvantages  have  generally  received  less  consideration. 
But  experience  has  shown  that  certain  tropical  countries  are 
suitable  for  permanent  colonisation,  above  all,  most  of  the  ele- 
vated places  such  f.  i.  as  the  Andes  highlands  in  South  America, 
the  Mexican  highlands,  the  high  table-land  of  Abyssinia,  the 
Himalaya  Mountains  and  their  forerunning  chains  in  India, 
etc. ;  there  also  are  some  limited  localities,  even  in  the  neigh- 
bourhood of  flat  coast-lands,  or  small  islands  at  some  little  dis- 
tance from  the  main  shore  which  present  on  account  of  their 
exposed  situation  and  abundant  air-currents,  better  hygienic  con- 
ditions and  freedom  from  malaria.  Further,  there  are  some 
insular  regions,  f.  i.  among  the  Polynesian  group  the  Sandwich, 
and  Fidji  island,  which  bear  a  good  sanitary  reputation;  simi- 
larly St.  Helena  and  the  Cape  Verde  islands,  whilst  the  portion 
of  the  African  continent  lying  opposite  to  them,  Senegambia 
and  Upper  Guinea,  are  notoriously  unhealthy. 

Particularly  suitable  from  an  hygienic  point  of  view  is,  to  all 
appearances,  Queensland  and  even  its  territories  extending  right 
into  the  tropics. 

The  European  immigrants,  English,  German  and 
Dutch,  have  since  the  discovery  of  that  colony  by  Cook 
in  1770,  multiplied  steadily.  Thriving  towns  have 
sprung  up  in  which  there  is  an  European-like  traffic. 
Agriculture  and  mining  are  in  full  swing.  The  native 


1 66  HEALTH,  DISEASE,  MARRIAGE 

Australian  races  have  been  pushed  into  the  interior. 
The  public  health  is  excellent;  the  towns  are  free  from 
malaria  and  in  the  rural  districts  this  disease  is  very 
rare ;  the  reason  may  possibly  lie  in  the  peculiar  vegeta- 
tion of  the  open  eucalyptus  forests  which  permit  the 
heat  from  the  soil  to  escape  easily  during  the  night. 
There  are  cool  nights;  the  seasons  are  distinct.  There 
are  no  swamps. — The  Europeans  born  in  the  country 
have  developed  well  and  for  a  century  Germanic  tribes 
have  reproduced  themselves,  although  they  do  not 
exactly  live  under  a  highland  climate.  (Schellong.) 
For  a  description  of  the  climatic  conditions  of  the  German 
colonies,  the  reader  is  referred  to  Plehn's1  lectures. 

The  climate  of  Kameroon  is  characterised  by  an 
equable  oppressive  heat  without  considerable  variations 
in  the  mean  monthly  temperatures,  by  copious  dis- 
charges with  great  humidity  of  the  air  and  very  uniform 
winds,  conditions  which  prevail  in  the  West-African 
low-lands  generally.  The  mean  yearly  temperature  is 
about  25.4°  C.  and  the  humidity  of  the  air  very  great, 
88 %  on  an  average,  rising  to  92%.  The  northern  part 
has  only  one  rainy  season,  from  April  to  October, 
shortly  before  and  after  easterly  winds  of  extraordinary 
violence  rage ;  then  follows  the  dry  season.  In  the  south 
of  the  colony  this  marked  difference  is  no  longer  notice- 
able. During  the  day  there  are  sea-breezes  coming  from 
the  West,  and  at  night  land-breezes  from  the  East. — 
What  makes  the  Kameroon  low-land  climate  so  hard  to 
endure  is  the  almost  entire  absence  of  marked  differ- 
ences in  the  temperature  while  the  air  is  at  the  same 
time  almost  absolutely  saturated  with  vapour.  There  is 
here  in  opposition  to  German  East-Africa  no  season  of 
the  year  during  which  real  recuperation  is  possible;  even 
in  the  coolest  nights  the  temperature  goes  down  but  very 
rarely  below  20°.  More  favourable  conditions  are 
offered  by  the  mountains  rising  from  the  low-lands,  and 


*Tropenhygiene  mit   spez.   Beriicksichtigung  der  deutschen  Kolonien  1902. 


CLIMATE,  RACE  AND  NATIONALITY       167 

by  the  high  table-land  which  constitute  by  far  the 
greatest  portion  of  the  colony,  but  which  has  so  far  been 
very  little  utilised  for  colonisation  purposes. 

Togo  which  lies  in  close  proximity  has  an  average 
temperature  of  26.5,  two  rainy  seasons,  from  March  to 
June  and  from  September  to  November;  between 
November  and  March  there  are  dry  winds  blowing 
from  the  desert  and  which  are  known  by  the  name  of 
Hermattan. 

The  South- West-African  colony  belongs  in  its  north- 
ern part  which  forms  2/s  of  its  extent  to  the  tropical 
zone  proper;  the  southern  part  is  situated  in  the  Cape 
region.  It  is  noteworthy  that  the  colony  is  extraordi- 
narily poor  in  water.  The  coast-land  is  comparatively 
cool  on  account  of  the  cold  ocean-current  which  rises 
in  this  part  of  Africa  from  the  South  Polar  sea  and 
from  which  there  are  always  keen  south-west  winds 
blowing  landwards.  The  daily  variation  in  the  tempera- 
ture is  consequently  very  slight.  The  monthly  average 
in  Walfisch  Bay  is  14-17°,  the  seasonal  variations 
13.3-20.5°,  the  absolute  extremes  38°  and  3°. — The 
high  table-land  of  the  interior  has  in  spite  of  its  consid- 
erable elevation  a  higher  temperature  than  the  coast  on 
account  of  the  absence  of  the  influence  of  the  sea.  The 
changes  in  the  temperature  are  very  considerable,  the 
humidity  of  the  air  is  very  great,  and  the  yearly  tem- 
perature fluctuates  between  14°  and  19°.  In  the  interior 
of  the  colony  the  differences  in  the  temperature  are  con- 
siderable; in  Omaruru  there  have  been  observed  such 
extremes  as  38°  and  4°. — German  West-Africa  has 
generally  speaking  a  climate  which  Europeans  can  bear 
well. 

German  West-Africa  has,  like  Kameroon,  a  flat 
coastland  and  highlands  in  the  interior;  it  has  very 
much  less  rain  and  its  vegetation  is  therefore  far  less 
luxuriant.  In  the  northern  equatorial  coast-region  the 
mean  annual  temperature  is  about  25-26°;  and  there 
are  two  distinct  rainy  seasons,  between  March  and 


i68 


May,  and  in  November.  The  south  part  of  the  colony 
has  only  one  rainy  season,  from  the  middle  of  November 
to  the  middle  of  May. — The  rainfall  is  generally  less 
than  in  Kameroon,  and  the  rains  less  certain.  The 
humidity  of  the  air  at  the  coast  amounts  to  80-86%. — 
At  the  beginning  of  the  year  the  coast-land  is  under 
the  influence  of  the  north-east  monsoon  coming  with 
great  force  from  the  Asiatic  continent  over  the  Indian 
Ocean,  which  blows  night  and  day  as  a  warm  wind 
causing  often  at  night  unbearable  sultriness.  It  lasts 
until  May.  The  wind  veers  round  slowly  towards 
south-east,  gains  in  intensity,  and  has  a  strong  current- 
movement  directed  towards  the  Very  hot  Sahara;  this 
is  the  beginning  of  the  coolest  and  most  endurable  time 
of  the  year.  The  country  near  the  coast  which  is  situ- 
ated at  an  elevation  of  1000  m  presents  extraordinarily 
favourable  climatic  and  hygienic  conditions;  the  same 
may  be  said  with  regard  probably  to  large  tracts  in  the 
interior  which  have  not  however  as  yet  been  sufficiently 
explored  in  these  directions. 

New-Guinea  also  has,  like  Kameroon,  on  its  coast 
very  thick  forests  which  stretch  up  to  a  considerable 
height  as  far  as  the  mountains  some  of  which  are  close 
on  4000  m.  high  and  are  situated  to  a  great  extent 
near  the  sea.  Under  the  influence  of  the  forest  there  is 
an  extremely  uniform  sea-climate.  As  mean  tempera- 
tures we  can  take  26.1°  in  the  North,  and  26.9°  in  the 
South.  The  differences  between  the  coldest  and  warmest 
months  are  extremely  slight;  the  average  fluctuation  of 
the  daily  temperature  amounts  to  about  8°.  As  regards 
rainy  seasons  and  rainfall,  there  exist  very  great  differ- 
ences according  to  the  local  conditions  and  especially 
according  to  the  situation  of  the  high  mountains  in 
respect  to  the  direction  of  the  trade-winds.  Like  every- 
where else,  the  climate  on  the  mountains  is  particularly 
agreeable. 

The  Bismarck-Archipelago,  the  Marshall-islands, 
the  Samoa-group,  the  newest  colonial  acquisitions  in  the 


CLIMATE,  RACE  AND  NATIONALITY       169 

South  Sea,  the  Carolines  and  Ladrones  possess  an 
equable,  humid,  warm  climate  without  perceptible  daily 
or  monthly  variations,  moderate  eastern  air-currents 
interrupted  by  occasional  storms  and  copious,  fairly 
generally  distributed  discharges. 


PART  II 

Sexual  maturity. —  The  duration  of  human  life  is  like 
the  seasons  of  the  year,  sub-divided  in  four  periods.  With  the 
commencing  development  of  the  sexual  maturity  the  individual 
ceases  to  be  a  child,  and  as  every  organic  formation  takes  place 
slowly,  the  process  of  puberty  in  both  sexes  is  also  a  slow  one 
and  fluctuating  according  to  the  time. 

Menstruation. — The  period  of  menstruation  which  in 
Germany  begins  as  a  rule  at  the  commencement  of  the  I5th 
year  depends  upon  various  circumstances  so  that  considerable 
modifications  occur  in  different  places.  The  influence  of  race, 
climate,  nutrition,  mode  of  life,  growth,  employment,  bring- 
ing-up,  habitation,  dress,  customs,  sensuousness  and  physical  life 
is  well-known,  and  to  these  may  perhaps  be  added  as  a  deter- 
mining factor  the  hereditary  predisposition. 

Commencement  of  the  same. — As  a  general  prin- 
ciple it  may  be  said  that  the  more  southern  the  home  of  a 
nation  the  earlier  puberty  makes  its  appearance.  In  the  tropics 
sexual  maturity  begins  between  the  age  of  1 1  and  14,  in  our 
latitudes  between  13  and  16  and  in  the  north  between  15  and 
1 8.  But  Polar  people  also  acquire  maturity  at  an  early  age. 
Hitherto  this  has  been  observed  principally  in  the  Eskimos. 
Among  the  Samojedes  it  is  also  by  no  means  an  unheard-of 
thing  to  come  across  married  women  of  13  years  of  age.  A 
physiological  explanation  why  puberty  should  commence  sooner 
the  nearer  a  people  are  to  the  Equator  or  to  the  North  Pole  is 
not  as  yet  forthcoming. 

Those  who  have  studied  the  question  regard  climate  as  the 


170  HEALTH,  DISEASE,  MARRIAGE 

chief  cause  of  the  variations.  But  it  is  hardly  yet  possible  to 
distinguish  which  of  the  elements  constituting  a  climate,  namely 
mean  yearly  temperature,  geographical  longitude  and  latitude, 
elevation  above  the  level  of  the  sea,  proximity  of  the  sea,  etc., 
claims  the  preponderating  influence,  if  any,  in  the  matter,  and 
to  what  extent.  Race  is  probably  also  an  important  factor  with 
regard  to  the  commencement  of  menstruation,  but  it  is  difficult 
to  define  that  importance.  (Krieger.) 

(It  is  said  that  in  the  arctic  regions  the  quantity  of 
the  menstrual  blood  is  extraordinarily  small,  and  that 
the  Eskimo  women  menstruate  only  in  the  summer  time 
and  then  only  to  an  insignificant  extent;  on  the  other 
hand  menstruation  in  the  tropics  is  very  profuse.   In  our 
climate  the  quantity  of  the  menstrual  blood  is  estimated 
by  various  authors  between  100-250  grammes.) 
The  influence  exerted  on  the  appearance  of  menstruation  by 
a  luxurious  and  comfortable  mode  of  life  and  also  by  an  indul- 
gent bringing-up  may  be  seen  from  the  calculation  of  Brierre 
de  Boismont  for  Paris  which  shows  an  average  age  of  14  years 
and  4  months,  whereas  in  women  belonging  to  the  middle- 
classes  menstruation  begins  with   15  years  and  2  months,  in 
working- women  with  15  years  and  10  months  and  in  servant- 
girls  with  1 6  years  and  2  months. 

Experience  has  shown  that  generally  women  begin  to  men- 
struate later  in  country  districts  than  in  towns;  the  difference  is 
sometimes  as  much  as  6  months  or  a  year.  It  is  believed  that 
town-women  acquire  the  earlier  maturity  in  consequence  of  the 
more  intensive  excitements  to  which  they  are  subjected. 

The  figures  given  by  some  authors  may  be  quoted 
here:  According  to  Tilt,  Indian  women  menstruate  in 
Calcutta  (at  n  years  and  n  months)  sooner  than 
Negresses  in  Jamaica  (14  years  and  10  months),  and 
Eskimo  women  in  Labrador  (15  years  3  months) 
sooner  than  Danes  and  Norwegians  (16  years). 
Joachim  found  in  Hungary  the  average  age  of 
puberty:  16-17  >n  Slovack  girls,  15-16  in  Magyars,  and 
13-14  in  Jewesses.  Vogt  gives  for  Norway  16-17 
years  in  Laplanders,  and  15.2  in  Kwain-women.  Fre- 


CLIMATE,  RACE  AND  NATIONALITY       171 

quent  variations  occur  round  these  average  figures. 
Litzmann  says  that  in  Smyrna  one  sees  mothers  1 1  years 
old;  in  the  North  of  Persia  the  signs  of  female  fruit- 
fulness  appear  with  the  I3th  year,  and  in  the  South 
already  between  the  Qth  and  loth  year;  in  Eboe  on  the 
coast  of  Guinea  between  the  8th  and  9th  year.1 

The  average  age  at  which  young  girls  begin  to 
menstruate  in  non-European  countries  is  13  in  Pales- 
tine, 13-14  in  the  Singalese  of  Ceylon,  12-18  in  Siam, 
1 6  in  China,  15-16  in  Japan,  14  in  the  East-Indian 
Archipelago,  11-13  in  the  tropical  and  sub-tropical 
parts  of  South- America. 

End  of  the  same. — Where  the  natural  desire  appears 
precociously  early,  it  also  disappears  sooner,  and  the  produc- 
tiveness of  the  female  body  ceases  completely  at  the  3Oth  and 
often  already  at  the  25th  year.  Tacitus  certainly  uttered  a  true 
experience  in  ascribing  the  prolonged  youth  of  the  Germans  to 
their  late  marriages. 

As  regards  our  temperate  climate,  and  under  regular  cir- 
cumstances, we  may  say  that  menstruation  ceases  between  the 
45th  and  5Oth  year,  though  there  is  little  precision  about  it, 
and  that  the  menstruating  life  lasts  therefore  from  30  to  35 
years. 

Experience  teaches,  according  to  Scanzoni,  that  women  who 
begin  to  menstruate  at  a  very  early  age,  f.  i.  at  the  age  of 
10  or  u,  generally  enter  the  climacteric  earlier  than  others, 
so  that  the  menopause  occurs  at  40  or  42.  On  the  other  hand 
others  maintain  the  contrary,  namely  that  women  whose  men- 
struation commences  later  in  life  reach  the  climacteric  very 
early,  and  that  those  who  begin  to  menstruate  very  early  con- 
tinue to  do  so  until  a  comparatively  advanced  age. 

Certain  observations  seem  to  favour  the  view  that  among 

the  lower  classes  menstruation  ceases  sooner  than  in  the  upper. 

Mantegazza  has  established  climatic  differences  for 

Italy  in  the  sense  that  the  cessation  of  menstruation 

occurs  in  North  Italy  between  the  ages  of  44  and  46, 


lHensen,  Hermann's  Handbuch  d.  Physiologic,  Vol.  VI. 


172  HEALTH,  DISEASE,  MARRIAGE 

and  in  Central  Italy  between  45  and  47 ;  in  the  South 
it  falls  as  a  rule  in  the  45th  year,  but  it  may  be  delayed 
to  the  5Oth  or  6oth  year. 

Early  marriage  especially  before  complete  maturity, 
generally  results,  as  experience  shows,  in  early  decay. 
The  women  in  Bosnia  and  Herzegovina  begin,  accord- 
ing to  Roszkiewicz,  to  look  old  when  they  are  35  years 
of  age;  Tuke  mentions  that  the  Maori  women  when 
25  or  30  years  old  appear  more  like  40  or  50;  the 
cause  of  their  premature  decay  probably  lies  in  the  early 
beginning  of  their  sexual  life.  In  Chinese  women  men- 
struation lasts,  according  to  Mondiere,  at  the  utmost 
till  they  are  40  years  old,  in  the  Japanese  it  goes  on, 
according  to  Wernich,  until  the  end  of  the  fourth  decade. 
Kogel  says  that  the  custom  of  early  marriages  in  Java 
accounts  for  the  circumstance  that  Javanese  women  do 
not  become  pregnant  after  the  age  of  35,  and  Finke 
reports  that  Banganese  women  cease  to  conceive  at  the 
age  of  20. 

A  frequent  phenomenon  after  the  cessation  of  menstruation 
in  matronly  women  is  the  accummulation  of  adipose  tissue  in 
all  parts  of  the  body,  which  sometimes  assumes  extraordinary 
dimensions.  In  consequence  of  the  gradually  relaxing  and  more 
expansible  state  of  the  connective  tissue  the  adiposity  tends  in 
contrast  to  the  elastic  condition  in  young  women  to  form 
depressions  and  wrinkles. 

Duration  of  sexual  maturity  in  the  male  sex. 
The  commencement  of  puberty  cannot  be  ascertained  in  man  so 
accurately  as  in  woman;  it  is  assumed  that  the  former  becomes 
sexually  mature  about  one  year  later  than  the  latter.  The 
development  of  the  testicles  occasions  as  circumstances  show, 
an  intensive  growth  in  certain  definite  parts  of  the  male  body. 
The  most  noticeable  external  sign  consists  of  an  alteration  in 
the  voice;  the  beard  and  pubic  hair  begin  to  sprout;  the  bones 
and  muscles  become  stronger  and  the  generative  organs  receive 
their  complete  development.  The  rule  that  the  beauty  of  mam- 
malian male  animals  lies  in  their  full  bodily  strength  applies 
therefore  to  man  as  well. 


CLIMATE,  RACE  AND  NATIONALITY       173 

As  in  the  female  sex  so  in  the  male  the  signs  of  puberty 
show  themselves  in  hot  countries  at  an  earlier  age;  in  Egypt, 
f.  i.  according  to  Hartman  in  boys  of  between  1 1  and  15. 

The  prematurity  of  the  male  youth  in  the  tropics  is  account- 
able for  the  very  early  commencement  of  sexual  intercourse. 
The  unrestricted  social  customs  of  many  non-European  coun- 
tries afford  most  varied  opportunities  so  that  young  men  of 
1 6  or  17  are  in  the  habit  of  regularly  gratifying  their  sexual 
desires. 

In  the  advanced  age  of  the  man  the  process  of  sperm-forma- 
tion retrogrades  gradually.  According  to  Duplay  and  Dieu  the 
number  of  normal  spermatozoa  in  the  epididymis  diminishes, 
but  on  the  other  hand  there  are  many  misshapen  ones,  espe- 
cially with  deficient  tails. 

Semen  to  a  certain  extent  normal  is  occasionally  found  in 
very  old  men,  but  the  generative  faculty  begins  as  a  rule  to 
decline  in  the  6oth  year;  frequently  the  offspring  of  advanced 
age  are  imperfect. 

(Of  165  old  men  those  between  the  ages  of  60 

and   70,   showed   65.8%   with   production   of   semen; 

those  between  70  and  80,  59.5%,  and  those  between 

80  and  90,  48%.) 

Marriageable  age. — Law  and  custom  have  regulated 
the  marriageable  age.  As  a  rule  we  may  say  that  the  lower 
the  grade  of  social  civilisation  of  a  people  the  earlier  the  age 
at  which  its  girls  are  allowed  to  marry.  Improved  customs  raise 
the  regard  for,  and  the  value  of,  woman;  moreover  the  fact 
that  among  civilised  nations  marriage  renders  the  creation 
and  support  of  a  separate  household  necessary,  contributes 
materially  to  its  postponement.1 

Whilst  Lycurgus  forbade  all  young  Greeks  to  marry 

before  attaining  the  age  of  37,  Plato  demanded  for 

men  the  marriageable  age  of  30,  and  for  women  20. 

Under  the  Emperors  of  Rome  the  completed  I2th  year 

was  considered  as  a  sufficient  majority  for  marriage,  but 


^Ploss-Bartels:  Das  Weib  in  der  Natur-  und  Volkerkunde,  1898. — 
Peschl:  Volkerkunde,  1885. — Johannes  Ranke:  Der  Mensch,  1894. — 
Ratzel:  Volkerkunde,  1895. 


174  HEALTH,  DISEASE,  MARRIAGE 

there  are  proofs  that  girls  married  when  they  were  only 
1 1  years  old. 

The  less  civilised  European  nations,  especially  those 
in  the  South,  have  not  yet  discontinued  their  custom  to 
marry  their  girls  very  early.  Among  the  Ricas,  a  tribe  of 
the  southern  Albanians,  girls  marry  at  least  when  they 
are  12  and  boys  when  they  are  15,  and  yet  these  prema- 
ture marriages  do  not  seem  to  impair  at  all  the  really  ath- 
letic form  of  this  type  of  humanity.  It  is  however  to  be 
remembered  that  Albanian  women  are  considered  fully 
mature  at  the  age  of  12.  Among  modern  Greeks  on 
the  other  hand  sexual  maturity  does  not  occur  before 
the  age  of  14  or  15  in  females  and  1 6  or  17  in  males. 
The  Ruthenians  in  Hungary  are  also  in  the  habit  of 
giving  their  girls  in  marriage  when  12  years  old,  and 
of  the  southern  Slavs  it  is  reported  that  as  a  rule  their 
women  marry  when  they  have  completed  their  1 6th  year 
and  their  breasts  begin  to  swell. 

The  legislation  of  all  civilised  States  has  proceeded  from 
the  point  of  view  that  it  is  necessary  to  obviate  arbitrary  deci- 
sions, injurious  to  the  community,  by  definite  legal  enactments. 
Naturally  it  was  the  Church  first  that  interfered  in  questions 
relating  to  marriage,  and  canon-law  fixed  the  marriageable  age 
for  boys  at  14  and  for  girls  at  12.  An  analogous  regulation  is 
found  in  the  middle-ages  in  the  Longobardian,  Frisian,  and 
Saxon  laws  and  also  in  the  "Schwabenspiegel"  (a  south-German 
code  of  laws  founded  on  the  "Sachsenspiegel") .  The  present- 
day  German  law  fixes  as  the  minimum  age  for  men  20,  and 
for  women  16.  For  the  whole  of  Russia  there  is  a  law  in  force 
which  prohibits  under  pain  of  transportation  to  Siberia  mar- 
riage with  a  girl  under  16  years  of  age. 

Youthful  marriages  are  uncommonly  frequent 
among  extra-European  nations.  Not  without  influence 
on  the  custom  of  early  marriages  in  the  East  are 
probably  the  religious  institutions  which  act  in  associa- 
tion with  the  climatic  causes.  Marriage  is  one  of  the 
religious  duties  of  Mahometanism  and  Mahometan 
girls  are  permitted  to  marry  when  10  years  old. 


CLIMATE,  RACE  AND  NATIONALITY       175 

Oppenheim  says  with  regard  to  Turkish  women  that 
they  menstruate  at  the  age  of  10,  marry  at  12,  become 
soon  mothers,  are  very  prolific,  cease  to  menstruate  at 
20,  grow  old  and  decay  very  early. — Klunzinger  reports 
that  in  Upper  Egypt  boys  of  15  to  18  marry  girls  of 
12  to  14,  and  adds  significantly  that  these  marriages 
which  are  in  our  estimation  premature  are  moreover  to 
the  extent  of  about  two  thirds  entered  into  between 
cousins  without  showing  any  ill-effects  upon  their  fruit- 
fulness.  With  the  Chinese  it  is  customary  though  not 
legally  enacted  for  girls  not  to  marry  before  they  are 
15  but  to  wait  as  a  rule  till  they  are  16,  and  for  men 
not  before  they  are  20.  In  Japan  the  marriageable  age 
was  up  to  recently  in  men  16  and  in  women  13.  In 
North  Polynesia,  in  the  Hawaian  Archipelago,  girls 
are  said  to  be  ripe  for  marriage  in  their  8th  year,  but 
they  may  not  marry  before  they  are  14. — Among  the 
negroes  in  Africa  marriages  also  take  place  early,  and 
mothers  14  years  old  are  no  rarity.  Erman  has 
recently  recalled  the  circumstance  that  in  the  Aleutian 
island  Atcha  boys  may  marry  as  soon  as  they  can  drive 
a  "baidare"  (a  vehicle)  and  girls  when  they  can  sew 
properly,  that  is  generally  in  both  about  the  loth  year. 
Numerical  proportion  of  both  sexes. — Nature 
looks  to  it  that  there  shall  be  as  many  men  as  women  and 
provides  approximately  one  woman  for  every  man.  Among 
civilised  nations  it  is  proved  that  there  is  an  excess  of  male 
births. 

A  report  of  the  statistical  office  of  the  Italian  Minis- 
ter for  Agriculture  on  the  proportion  of  male  to  female 
births  for  a  period  of  19  years  and  with  respect  to 
32  countries  shows  that  there  are  constantly  105  boys 
born  to  every  100  girls. 

In  Europe  the  female  sex  shows  in  the  first  periods  of  life 
a  markedly  smaller  mortality  than  the  male;  moreover,  the 
shorter  duration  of  life  in  men  is  a  widely  spread  phenomenon 
which  is  to  some  extent  easily  explained.  On  this  account  there 
is  in  the  later  periods  of  life  an  alteration  in  the  original  pro- 


176  HEALTH,  DISEASE,  MARRIAGE 

portion  to  the  disadvantage  of  the  male  sex.  The  entire  popu- 
lation of  Europe  shows  therefore  a  predominance  of  women 
over  men  so  that  there  are  102.1  of  the  former  to  100  of  the 
latter.  But  this  does  not  apply  to  all  countries  in  the  world, 
for  some  show  exactly  the  reverse.  In  the  proportion  of  women 
to  men  there  is  also  a  racial  element  at  work;  on  the  whole 
there  are  in  Europe  more  men  than  women  among  the  Latin 
and  South  Slavonic  nations,  and  more  women  than  men  among 
the  Teutonic  and  North  Slavonic  peoples. 

But  human  customs  and  practices  as  well  as  influences 
whose  nature  we  do  not  quite  comprehend  as  yet,,  do  their 
utmost  to  alter  this  proportion.  Economic  and  political  meas- 
ures tend  sometimes  and  in  some  places  to  increase  the  number 
of  one  sex  over  the  other  as  f.  i.  emigration,  military  require- 
ments, etc. 

Monogamy  always  acts  compensatingly  to  a  certain  extent, 
and  re-establishes  the  balance  in  a  comparatively  short  time, 
where  it  is  disturbed  as  for  instance  in  newly-opened  countries 
through  the  overwhelming  immigration  of  men.   On  the  other 
hand  polygamy  is  supposed  to  be  mainly  responsible  in  uncul- 
tured nations  for  the  disturbance  in  the  numerical  equality  of 
the  sexes  and  for  the  dangerous  fluctuations  of  the  population. 
In  nations  of  a  low  type  which  constantly  struggle 
against  misery,  the  number  of  women  is  apparently  far 
behind  that  of  the  men.    According  to  the  census  of 
1 88 1  the  natives  in  the  South  Australian  colony  num- 
bered 5628  individuals  of  whom  2430  were  women; 
of  the  883  children  only  405  were  females.  The  infanti- 
cide prevalent  among  such  tribes  generally  affects  more 
the  weaker  sex,  and  its  surviving  members  suffer  too 
much  from  the  greater  share  of  hardships  which  falls 
to  the  lot  of  the  women-folk  of  wandering  nations. 

Where  a  population  is  declining  it  seems  that  the 
female  portion  disappears  more  rapidly  than  the  male. 
Such  nations  are  generally  warlike ;  the  loss  of  a  woman 
is  therefore  no  loss  to  them.  Single  women  are  allowed 
to  perish  unmercifully.  The  harder  the  struggle  for 
existence  the  greater  the  necessity  of  the  weaker  sex  to 


CLIMATE,  RACE  AND  NATIONALITY       177 

seek  the  companionship  of  the  stronger  one ;  this  is  the 
reason  why  in  such  countries  as  Greenland  single  women 
find  it  impossible  to  exist  long  without  male  children. 
One  of  the  characteristics  of  the  colonies  is  the  smaller 
number  of  women,  because  women  emigrate  as  a  rule  less  than 
men.    Migrations  disturb  the  progress  of  a  population;  in  the 
emigrant  countries  more  women  remain  behind,  in  the  immi- 
grant a  preponderance  of  men  is  formed.   An  excess  of  women 
over  men  is  present  among  nations  in  all  states  of  civilisation 
whose  male  half  has  been  reduced  by  war  or  emigration. 

The  state  of  unrest  of  many  nations  which  are  in  a 
barbarous  condition  is  not  favourable  to  the  growth  of 
the  female  element.  There  are  large  emigrations  as  f.  i. 
those  of  the  Chinese  to  the  shores  of  the  Pacific  Ocean 
and  to  the  West-Indies  in  which  the  female  sex  is  not 
represented  by  as  much  as  i%.   In  British  Guiana  there 
are  in  spite  of  the  regulated  emigration  of  Indians  only 
about  10,000  coolie-women  to  30,000  men. 
Polygamy  causes  in  some  tribes  the  number  of  women  to 
increase,  in  others  to  decrease.     A  more  just  sub-division  of 
property,  such  as  is  claimed  by  some  in  other  directions,  has  in 
any  case  been  attained  with  regard  to  women  by  the  system 
of  monogamy  which  prevents  an  accumulation  of  women  in  the 
hands  of  rich  individuals  and  especially  in  those  of  heads  of  State. 
In  so  far  as  civilisation  depends  upon  the  steady  and  regular 
growth  of  nations  it  owes  this  blessing  to  the  decline  of  polyg- 
amy. Wherever  the  latter  prevails, — and  all  uncultured  nations 
are    formally    or    practically    polygamous, — the    women    are 
unequally    divided    and    the    number    of    births    diminishes. 
Many  men  go  without  women  even  where  the  latter  are  greatly 
in  excess  as  f .  i.  in  Uganda ;  a  few  know  how  to  obtain  a  great 
number.    But  these  are  not  able  to  make  up  for  the  loss  in 
births  caused  by  the  compulsory  celibacy  of  so  many  others. 
Malthus  already  knew  that  in  Turkey  the  monogamous  mar- 
riages of  the  Christians  were  more  productive  than  the  polyg- 
amy of  the  Turks.    This  assertion  has  recently  been  amply  con- 
firmed by  modern  investigators. 

The  necessity  to  work  acts  regulatingly  on  these  conditions. 


178  HEALTH,  DISEASE,  MARRIAGE 

Where  the  natives  are  in  regular  employment  their  physical 
well-being  and  their  favourable  social  relations  are  evident. 

Baelz  says  that  the  infantile  mortality  among  the 
working  populace  of  Japan  is  low,  whereas  it  is  high 
among  the  decrepit  higher  ranks.  Although  polygamy 
is  legally  permitted  in  China  and  Japan  it  has  fortu- 
nately for  them  never  become  so  universal  there  as  in 
other  countries. 

Special  marriage-forms. —  Marriages  are  called 
polygamous  or  polyandrous  according  as  the  household  is  con- 
ducted by  one  man  with  several  wives,  or  where  one  woman 
belongs  to  several  husbands  at  the  same  time.  Polygamy  is- 
prevalent  all  over  Africa;  it  was  also  permitted  by  almost  all 
Asiatic  nations ;  in  America  on  the  other  hand  it  is  seldom  met 
with. 

There  is  an  often  quoted  statement  to  the  effect  that 
in  polygamy  female  births  preponderate  and  that 
Nature  adapts  herself  so  to  speak  to  the  locally  pre- 
vailing marriage-customs.  This  is  however  doubted  and 
credible  observers  have  testified  that  boys  and  girls  are 
born  in  the  harems  in  exactly  the  same  proportions  as 
under  monogamous  circumstances. 

Breeders  of  animals  assert  that  in  race-horses,  grey- 
hounds and  Cochin-China  fowls  the  proportion  of  the 
sexes  in  births  remains  undisturbed  though  the  strictest 
polygamy  is  employed  in  these  animals.     (Darwin.) 
Genuine  polyandry  is  seen  among  the  tribes  which  form  a 
transition  between  Asiatics  and  Americans,  namely  among  the 
Eskimos,  the  Aleutians,  the  Kon jacks,  the  Koljuschis,  in  whom 
other  sexual  aberrations  are  also  not  wanting;  also   among 
the  Maoris  of  New-Zealand,  and  among  some  tribes  of  the 
southern  Malabar  coast  and  the  Nilgiri  mountains,   and  in 
Ceylon. 

Origin  of  marriage. — Lubbock  maintains  that  early 
man  did  not  practice  nuptial  cohabitation  and  that  the  women 
were  common  property  of  all  the  male  members  of  the  tribe. 
He  describes  the  condition  as  hetarism.  The  majority  of  ethnog- 
raphers and  anthropologists  do  not  share  this  opinion;  there 


CLIMATE,  RACE  AND  NATIONALITY       179 

may  have  been  mistakes  in  the  interpretation  of  certain  forms 
of  marriage  and  of  the  influence  of  local  barbarism.  The  view 
that  pre-historic  man  did  not  know  what  marriage  is  seems 
incredible,  as  we  find  even  in  animals  a  sort  of  strict  pairing; 
Darwin1  also  has  denied  the  probability  of  a  common  property 
in  women. 

Adolf  Bastian  in  a  lecture  before  the  Berlin  Anthropological 
Society  has  expressed  most  admirably  his  views  on  the  develop- 
ment of  the  different  forms  of  marriage,  in  which  the  condi- 
tions of  Matriarchate  and  Patriarchate  play  a  very  important 
part.  There  is  no  question  in  the  former  of  any  privileges 
attached  to  the  female  sex,  but  rather  the  profoundest  contempt 
such  as  the  strong  always  have  for  the  weak  where  might  is 
right.  In  the  primary  horde  it  would  have  been  the  physically 
and  morally  strongest  men  who  appropriated  the  women  first 
and  naturally  they  would  select  the  younger  and  most  attractive 
ones.  With  the  arrival  of  offspring  the  father  would  decline 
all  further  obligations,  and  the  latter  would  devolve  entirely 
upon  the  mother. 

A  transition  to  patriarchate  is  occasioned  by  the  sympathy 
springing  up  in  the  father's  breast  for  the  children  of  his  flesh 
and  blood,  though  perhaps  only  on  account  of  the  assistance 
which  they  might  render  him  in  his  agricultural  pursuits  associ- 
ated with  a  more  settled  mode  of  life,  and  because  it  would  be 
a  disadvantage  to  forego  this  assistance. 

Consanguinity. — In  many  tribes  we  meet  with  the 
custom  that  the  closest  relationship  is  not  only  no  obstacle 
against  marriage  but  rather  an  additional  advantage,  and  on 
the  other  hand  we  see  in  others  that  such  marriages  are  pro- 
hibited not  only  between  close  blood-relations  but  also  between 
persons  whom  we  should  at  the  present  day  hardly  regard  as 
relations  at  all,  f.  i.  foster-brother  and  foster-sister.  In  civilised 
countries  definite  laws  have  been  passed  regulating  the  degrees 
of  relationship  which  act  as  impediments  to  marriage,  but  the 
laws  of  the  different  States  differ  materially  from  one  another. 
The  hereditary  influence  of  consanguineous  marriages  upon  the 


'Descent  of  Man,  Vol.  II,  p.  358. 


i8o  HEALTH,  DISEASE,  MARRIAGE 

offspring  is  of  great  importance  to  the  hygiene  of  marriage  and 
for  this  reason  specially  dealt  with  in  a  separate  chapter  of  this 
treatise. 

Infantile  marriages. — A  brief  reference  to  marriages 
between  children  is  here  indicated.  Very  few  nations  practise 
the  habit  of  marrying  their  children  when  they  are  very  young 
— between  4  and  9  years — ,  but  the  age  of  10  or  12  is  a  very 
prevalent  marrying  age.  Such  early  marriages  do  not  of  course 
mean  in  every  case  an  immediate  commencement  of  sexual  inter- 
course. Among  the  Chinese  f.  i.  the  marriage  contract  is  often 
concluded  when  the  girl  is  only  6  years  old,  and  the  young  wife 
enters  the  household  of  her  husband;  but  the  consummation  of 
the  marriage  does  not  take  place  before  the  girl  is  at  least 
12  or  13,  when  as  a  matter  of  fact  she  is  already  fully 
developed.  To  our  regret  we  hear  that  Europeans  in  Celebes 
are  in  the  habit  of  keeping  concubines  of  the  age  of  12  or  13, 
and  the  custom  is  so  general  there  that  no  one  seems  to  find 
fault  with  it.  India  is  always  spoken  of  as  the  classical  land  of 
child-marriages.  On  account  of  the  numerous  physical  injuries 
which  these  children  suffer  in  their  marital  intercourse,  an  agita- 
tion is  at  present  on  foot  to  abolish  by  law  this  institution  so 
horrible  to  the  feelings  of  every  humanitarian.  There  are  cases 
where  some  of  the  poor  creatures  have  become  mothers  without 
ever  having  menstruated.  It  is  astonishing  to  hear  that  the  child- 
birth of  such  young  mothers  often  takes  place  without  any 
injury,  though  many  of  them  do  lose  their  lives. 

It  seems  to  be  an  established  fact  that  premature 
sexual    intercourse    is    capable    of    hastening    the    first 
appearance  of  menstruation;  experiments  which  Coste 
has  made  on  rabbits  also  seem  to  show  that  irritation 
of  the  genital  organs  can  expedite  the  maturation  of  the 
ova  and  their  separation  from  the  ovaries. 
Premature  senility  and  an  early  extinction  of  the  conceptive 
faculty  are  said  by  many  authors  to  be  a  direct  consequence  of 
infantile  marriages.    (Ploss-Bartels.) 

Beauty  of  female  sex. — The  consideration  of  the 
beauty  of  women  from  the  aesthetic  point  of  view  is  the  con- 
cern of  the  artist.  The  scientist's  demand  is  that  the  female 


CLIMATE,  RACE  AND  NATIONALITY       181 

body  shall  be  so  constituted  in  all  its  parts  as  to  be  fully  equal 
to  the  sexual  functions  of  the  female  sex. 

Climatic  and  different  other  external  circumstances  are  as  a 
rule  of  decisive  influence,  sometimes  beneficial  and  sometimes 
injurious,  upon  the  physical  and  moral  development  of  human 
nature  in  general,  and  the  female  sex  especially.  The  position 
of  woman  in  the  social  life  and  the  activity  allotted  to  her  by 
convention  among  all  nations  contribute  to  the  more  or  less 
beautiful  development  of  the  female  form.  Among  uncultured 
people  in  their  state  of  naturalness,  among  stunted  tribes  with 
primitive  customs  the  contrast  between  man  and  woman  is  not 
pronounced  but  rather  obscure.  With  the  growth  of  civilisation 
it  becomes  clearer  and  clearer  and  it  advances  step  by  step. 
Rural  populations  living  in  a  secluded  state,  and  proletarians 
constantly  bowed  under  the  yoke  of  hard  manual  labour  exhibit 
in  both  sexes  almost  the  same  physiognomy  (Riehl) .  Among 
civilised  nations  living  in  comfort,  beauty  and  nobility  of  fea- 
tures progress  from  generation  to  generation  along  with  the 
mental  improvement,  though  nature  does  like  occasionally  to 
create  beautiful  female  types  under  the  most  unfavourable 
external  circumstances  and  among  nations  in  a  low  state  of 
culture.1 

Cordier  said  in  a  thesis  laid  before  the  Anthropo- 
logical Society  of  Paris:  Beauty  is  not  at  all  the  prop- 
erty of  one  race  or  another.  Each  race  differs  as  regards 
its  own  beauty  from  the  other  races.  Rules  of  beauty 
are  therefore  not  general,  they  must  be  studied  specially 
for  each  race. 

Although  the  conception  of  beauty  is  uncommonly 
different  among  the  different  races  and  nations,  it 
becomes  in  the  male  suitors  an  unconscious  cause  in  the 
selection  of  their  breeding-partners.  Darwin  maintains 
that  women  transmit  their  beauty  to  their  female  chil- 
dren to  a  greater  extent  than  to  their  male  offspring; 
and  for  this  reason  women  have  gradually  become  more 
beautiful  than  men. 


1Ploss-Bartels.        See  also  Strats,    "Rassenschonheit  des  Weibes"    1901, 
and  "Schonheit  des  weiblichen  Korpers"   1900. 


182  HEALTH,  DISEASE,  MARRIAGE 

Through  the  mixture  of  races  the  female  beauty 
gains  in  quality,  but  it  is  not  yet  known  which  peculiari- 
ties of  the  father  or  mother  are  of  greater  influence  on 
the  products  of  the  race-mixture. 

Nations  which  intermarry  only  within  their  own  race  create 
descendants  who  exhibit  most  markedly  the  characteristics  of 
that  race.  Intermixture  with  other  races  produces  by  hereditary 
transmission  in  the  offspring  either  paternal  or  maternal 
peculiarities. 

There  are  thousands  of  ethnographical  proofs.  If 
a  negro  mixes  with  an  Egyptian  woman,  the  children 
have  yet  the  hair  of  the  negro  race,  but  the  grand- 
children's hair  is  already  smooth  and  they  resemble  the 
Egyptians.  Europeans  and  Turks  procreate  with 
Abyssinian  women  children  who  approximate  in  their 
physical  type  Spaniards  and  Portuguese.  The  cross- 
products  of  Javanese  and  Europeans  are  strikingly 
good-looking;  they  have  neither  the  turned-up  nose  of 
the  Malay  nor  the  big  smiling  mouth  and  the  narrow 
eyes.  Finsch  saw  a  two-year-old  child  of  a  white  man 
by  a  woman  from  New-Guinea  which  looked  like  a 
sun-burnt  European  child  with  curly  fair  hair,  dark  eyes 
and  red  lips.  An  interesting  type  is  that  of  the  mulatto- 
woman,  a  product  of  the  union  between  a  white  man 
and  a  negress,  on  account  of  her  slender  build,  delicate 
hands,  rounded  breasts,  tall  stature,  small  and  dainty 
feet,  and  all  this  associated  as  a  rule  with  a  frolicsome 
disposition. 

A  universal  admission  as  to  the  representative  of  which  race 
or  mixture  of  races  deserves  the  first  beauty-prize  has  as  yet 
not  been  possible  to  obtain  nor  is  it  likely  that  one  will  ever  be 
obtained,  seeing  that  opinions  on  the  subject  of  beauty  are  as 
different  as  the  conceptions  of  beauty-ideals. 

Mixture  of  races. — The  definition  of  "kind"  by 
Decandolle  is  that  "it  is  the  union  of  all  single  individuals 
who  resemble  each  other  more  than  others,  and  whose  sexual 
intercourse  produces  fruitful  descendants  who  in  their  turn  also 
renew  themselves  by  succeeding  generations." 


CLIMATE,  RACE  AND  NATIONALITY       183 

Flourens  was  also  of  the  opinion  that  fruitfulness  establishes 
the  permanency  of  peculiarities;  different  kinds  produce  how- 
ever cross-products  of  limited  fruitfulness  only. 

It  was  formerly  believed  that  the  offspring  of  different 
human  races  possess  no  fruitfulness.  But  this  is  by  no  means 
the  case.  Even  in  the  breeding  of  animals  it  is  seen  that  those 
which  avoid  each  other  sexually  when  in  a  state  of  freedom 
can  be  brought  together  for  the  purpose  of  mixing  their  blood 
and  characteristics.  It  has  never  been  denied  that  Aryan  Hindus 
can  produce  mixed  descendants  by  Dravidas,  and  that  these 
descendants  are  in  their  turn  capable  of  reproduction ;  the  same 
may  be  said  of  Chinese  with  European  women,  and  of  Arabs  with 
negresses.  It  is  however  frequently  said  that  mulattoes  do  not 
survive  many  generations.  The  women  of  mixed  blood  in  Central- 
America  are  also  said  to  be  sterile  as  a  rule.  But  the  cause  of 
this  certainly  frequent  occurrence  is  by  no  means  a  physiologi- 
cal one.  It  is  due  rather  to  immoral  life  and  early  excesses. 
On  the  other  hand  mulatto-women  of  every  imaginable  prolific- 
ness  are  by  no  means  rare.  The  fact  that  on  the  island  of  Cuba 
and  in  Hayti  half-blooded  populations  have  grown  up  in  hun- 
dreds of  thousands  is  at  least  sufficient  proof  that  the  descend- 
ants of  South-European  Creoles  and  Negroes  are  reproductive. 
Complete  sterility  of  the  Anglo-Saxon  mulattoes  in  Jamaica 
has  only  been  observed  temporarily  and  is  even  contradicted 
altogether.  A  further  mixed  race  in  America  are  the  Sambos, 
descendants  of  Negroes  by  women  belonging  to  the  so-called 
red  aborigines.  They  are  often  seen  among  the  Creek-Indians 
in  the  United  States,  and  also  in  Central  America  and  the 
inhabitants  of  the  coasts  of  Panama  and  Columbia  bear  decided 
marks  of  half-African  blood.  In  the  countries  which  were 
formerly  Spanish  colonies  there  are  millions  of  cross-products 
by  Europeans  and  native  American  women  known  under  the 
generic  name  of  Mestees.  In  South  America  there  is  a  large 
population  of  mixed  offspring  of  Negroes  and  Portuguese,  in 
Chili  one  of  Indians  and  Spaniards;  in  other  parts  of  this 
continent  there  are  the  most  complicated  mixtures  between 
Indians,  Negroes  and  Whites,  but  it  is  just  this  triple  admixture 
which  supplies  the  strongest  proof  of  the  reciprocal  fruitful- 


1 84 

ness  of  different  races.  The  mixed  race  in  Paraguay  surpasses 
even  in  fruitfulness  the  two  races  from  which  they  have  sprung. 
An  extraordinary  reproductive  faculty  is  witnessed  in  the 
mulattoes  who  are  very  plentiful  in  the  European  colonies  as 
well  as  in  the  States  of  South  America.  The  reason  why  there 
are  so  few  mixed  people  in  Australia  is,  as  shown  by  judicial 
investigation,  to  be  found  in  the  fact  that  the  natives  are  in 
the  habit  of  killing  their  impure  children.  (Darwin.)  Tas- 
manian  women  have  also  brought  into  the  world  numerous 
cross-products.  Of  greater  importance  still  is  the  circumstance 
that  half-blooded  individuals  have  resulted  from  unions  between 
Europeans  and  Hottentots,  for  if  there  is  any  type  of  humanity 
which  may  claim  to  be  regarded  as  a  special  kind  it  is  surely 
these  aborigines  of  the  Cape-countries. 

These  cross-products  are  called  in  their  own  country 
partly  bastards,  and  partly  Griquas;  this  last  term  has 
however  been  misused  so  much  that  it  does  not  convey 
any  longer  a  restricted  anthropological  meaning. 
(Frltsch.) — Finally  there  have  been  many  kinds  of 
intermixture  between  British,  Dutch,  Mulattoes,  and 
Negroes  in  out-of-the-way  islands,  such  as  Tristan 
d'Acunha. — Le  Vaillant  says:  Hottentots  produce 
when  they  marry  among  themselves  3  or  4  children; 
when  they  unite  with  Negroes  this  number  is  trebled 
and  it  becomes  even  higher  when  they  intermix  with 
Whites. 

The  colour  of  the  skin  alters  rapidly  by  the  mixture  of 
Europeans  with  brown-yellow  South-African  women;  this  does 
not  take  place  so  quickly  where  negroes  mix  with  European 
women,  the  negro-blood  comes  to  the  surface  in  such  cases  even 
in  later  generations.  The  descendants  of  Europeans  by  coloured 
native  women  are  called  Creoles  in  such  extra-European  coun- 
tries as  were  formerly  Spanish,  French  or  Portuguese  colonies, 
the  offspring  of  Europeans  by  Indian  women  are  called  Mestees 
(in  Mexico  also  Ladinos,  in  Ecuador,  Peru  and  Chili  also 
Cholos),  those  of  Europeans  or  Creoles  by  negresses  are  called 
Mulattoes,  and  those  of  Indians  by  negresses,  Sambos  or 
Chinos. 


CLIMATE,  RACE  AND  NATIONALITY       185 

Where  mulattoes  intermix  with  whites  the  negro-blood  is 
indicated  in  the  subsequent  generations  by  fractions:  a  terce- 
roon  is  the  offspring  of  an  European  by  a  mulatto-woman,  a 
quadroon  one  by  a  terceroon,  and  so  on  from  quintroon  to 
octoroon.  The  quintroon  is  hardly  in  any  way  different  from  a 
white,  and  even  before  the  abolition  of  slavery  in  the  United 
States  he  was  already  regarded  by  law  as  a  white.  While  the 
mulatto  is  still  very  much  like  a  negro,  the  individuals  pos- 
sessing less  negro-blood  show  yet  the  violet  colour  of  the  nails 
and  a  bluish  ring  around  the  eyes  as  characteristic  signs,  and 
these  are  the  last  to  disappear.  Vice-versa,  if  mulattoes  mix 
with  negroes,  the  white  blood  becomes  quite  extinct  again  in 
the  4th  or  5th  generation.  The  success  of  intermixture  is  how- 
ever by  no  means  regular  or  calculable  beforehand.  Just  as 
among  ourselves  the  union  between  fair-complexioned  and  dark 
people  is  not  always  productive  of  intermediate  stages  between 
the  two  types  but  sometimes  of  fair  children  and  sometimes  of 
dark,  so  the  offspring  of  marriages  between  whites  and  coloured 
people  may  incline  either  to  the  one  type  or  the  other. 

Even  in  later  generations  there  is  often  a  reversion 
to  an  ancestral  link.  With  regard  to  the  mixture  of 
races  between  Whites  and  Kaffirs  Fritsch  says:  The 
behaviour  of  the  colour  in  the  skin  of  the  cross-products 
is  very  singular,  and  it  is  difficult  to  lay  down  any  laws. 
What  is  certain  is  that  such  persons  have  often  a  strik- 
ingly dark  skin  which  is  as  far  as  strength  is  concerned 
not  one  whit  behind  that  of  the  pure  race,  and  also  that 
later  generations  have  a  tendency  to  atavism,  inasmuch 
as  the  grandchildren  are  more  like  their  grandfathers 
than  the  great-grandchildren. 

The  very  light  mixed  race  of  Europeans  and  Hindus  is 
known  as  Eurasians  or  Australasians;  they  are  very  numerous 
and  politically  of  great  influence  in  their  country. 

Marriage  in  the  tropics  from  the  medical 
point  of  view. — The  hygienic  advantages  of  marriage 
and  of  a  household  of  one's  own  are  for  the  male  inhabitants 
of  the  tropics  of  particular  importance;  a  regulated  mode  of 
life,  suitable  nourishment,  a  healthy  home,  and  similar  other 


186  HEALTH,  DISEASE,  MARRIAGE 

necessities  are  often  very  hard  to  obtain  otherwise  under  tropi- 
cal conditions.  Many  a  promising  career  has  been  shattered 
through  the  impossibility  of  finding  the  necessary  domestic  com- 
fort for  the  preservation  of  health  under  circumstances  of  an 
exhausting  nature.  And  what  a  blessing  it  is  to  have  a  wife 
when  sickness  demands  careful  and  intelligent  nursing!  It  is 
more  correct  to  say  that  it  is  in  the  tropics  where  both  doctor 
and  patient  experience  the  want  of  the  external  conditions 
created  by  the  married  state.  Some  of  the  objections  which 
Europeans  in  the  tropics  have  against  marriage  from  their  point 
of  view  and  from  that  of  the  eventual  offspring  are  often  practi- 
cally disposed  of  by  having  recourse  to  concubinage. 

Though  we  must  bear  in  mind  the  unfavourable  climatic 
influences  on  the  female  sex,  it  would  nevertheless  be  a  mistake 
to  condemn  on  principle  the  marriage  of  every  European  in  the 
tropics.  As  in  everything  else  where  medical  advice  is  needed 
it  behoves  us  to  consider  each  case  on  its  individual  merits. 

We  cannot  enter  here  into  a  discussion  how  far  the  relations 
between  the  various  diseases  and  marriage  with  respect  to 
climate  and  race  present  special  features.  It  is  for  the  first  time 
that  this  subject  is  dealt  with  in  this  work  by  specialists  in  a 
comprehensive  manner.  It  must  be  left  to  some  future  occasion 
to  give  my  own  experiences  and  those  of  others  on  the  basis  of 
the  above  mentioned  relations.  For  the  present  I  must  confine 
myself  to  the  mention  of  the  geographical  distribution  of  the 
two  diseases  which  are  as  is  well  known,  of  the  greatest 
importance  to  marriage  and  the  offspring  resulting  from  it, 
namely  syphilis  and  tuberculosis. 

Distribution  of  syphilis.— Scheube(Archiv  f.  Schiffs- 
und  Tropenhygiene  1902)  has  instituted  a  general  investiga- 
tion on  a  large  scale  and  ascertained  by  means  of  it  that 
syphilis  has  become  almost  universally  prevalent  in  tropical  and 
sub-tropical  countries.  There  are  only  a  few  isolated  places  not 
yet  open  to  the  commerce  of  the  world,  in  Further  India,  on 
the  Dutch-India  islands,  in  Luzon,  in  the  heart  of  Africa,  in 
New-Guinea,  and  the  island-groups  of  the  South  Sea,  in  the 
furthest  interior  of  Brazil,  whose  inhabitants  are  as  yet  free 
from  the  ravages  of  this  dreadful  scourge.  It  is  unfortunately 


CLIMATE,  RACE  AND  NATIONALITY       187 

an  incontrovertible  fact  that  the  carriers  of  civilisation  have  in 
newly  opened-up  countries  introduced  along  with  the  blessings 
of  culture  the  curse  of  syphilis.  Wherever  discoverers,  con- 
querors, explorers,  sea-farers  and  merchants  have  made  their 
appearance  syphilis  was  not  long  in  following  close  at  their  heels 
and  in  infecting  countries  which  were  before  as  clear  of  it  as 
they  were  of  every  vestige  of  civilisation;  like  a  merchandise, 
as  Mense  says,  syphilis  spreads  by  stages  from  tribe  to  tribe. 

Though  syphilis  is  present  in  all  warm  countries  with 
few  exceptions,  its  distribution  in  the  same  is  an  unequal  one. 
Of  the  greatest  influence  on  the  latter  is  the  purity  or  laxity 
of  the  morals  reigning  among  the  inhabitants,  and  particularly 
the  extent  which  prostitution  has  attained.  The  more  freely  and 
unrestrictedly  prostitution  goes  on  in  a  country  the  greater  as 
a  rule  the  prevalence  of  syphilis. 

Seaumanoir  (Arch,  de  med.  navale  1890)  says  it  is 
generally  well-known  that  in  the  Sandwich-Islands 
almost  the  entire  native  population  is  affected  with 
syphilis,  v.  During  Pascha  estimates  that  syphilis  is 
largely  and  equally  distributed  in  Turkey  and  Asia 
Minor  among  all  races,  Circassians,  Kurds,  Tartars, 
Turkomans,  Arabs,  Christians  and  Mahometans. — In 
Burmah  after  the  abolition  of  the  control  of  prostitutes 
the  percentage  of  venereally-diseased  in  the  British 
army  rose  from  155  to  376  per  thousand.  Acquired 
syphilis  is  very  often  seen  among  the  native  Eurasian 
school-boys  under  16  years  of  age.  In  Siam  at  least 
70-80%  of  the  male  European  population  are  affected, 
and  among  the  Siamese  it  is  a  rare  thing  to  come  across 
a  man  even  if  belonging  to  the  highest  circles  who  has  not 
had  syphilis. 

The  most  severely  afflicted  localities  in  Asia  are  the 
earliest  habitations  of  the  disease,  India,  China  and 
Japan.  In  the  Dutch  army  syphilis  is  present  about 
four  times  as  often  among  the  Europeans  as  among  the 
natives,  most  of  whom  are  married. 

The  inhabitants  of  the  African  coasts  are  severely 
affected,  probably  through  infection  from  Europe, 


1 88  HEALTH,  DISEASE,  MARRIAGE 

whilst  Central  Africa  suffers  to  a  comparatively  mild 
extent  only.  On  the  East  coast  of  the  African  continent 
and  on  the  East  African  islands  the  number  of  syphi- 
litics  is  estimated  at  5/6  of  the  whole  native  population. 
In  Durban  (Natal)  syphilis  exists  among  all  classes  of 
society.  The  frequency  dates  however  from  the  discov- 
ery of  the  gold-mines  which  have  attracted  prostitutes 
from  all  parts  of  the  world.  In  Windhoek  (German 
West  Africa)  half  the  number  of  Hottentots  and 
mixed  products  applying  for  medical  treatment  suffer 
from  syphilis. — In  Kaiser  Wilhelm's  Land  (New 
Guinea)  syphilis  was  according  to  the  unanimous  opin- 
ion of  explorers  unknown  before  Europeans  settled 
among  the  native  Papuans.  The  latter  are  very  par- 
ticular in  not  permitting  their  women  to  have  sexual 
intercourse  with  white  men.  Soft  chancre  and  gonor- 
rhoea are  also  said  to  be  unknown  there. 

In  the  Bismarck  Archipelago  where  the  native 
women  are  easily  procurable  gonorrhoea  has  become 
very  frequent  among  the  natives,  and  syphilis  which 
was  there  also  unknown  must  by  now  be  quite  a  com- 
mon occurrence. 

It  would  be  possible  to  continue  this  selection  also 
with  reference  to  the  American  Continent. 
This  general  prevalence  of  syphilis  is  naturally  not  without 
influence  on  the  public  health  and  on  the  relation  between  births, 
miscarriages  and  deaths,  and  it  often  represents  an  important 
cause  of  the  constant  decline  of  the  native  population  observed 
in  some  localities. 

Generally  speaking  the  course  of  syphilis  in  the  case  of 
Europeans  is  the  same  in  the  tropics  as  in  Europe,  but  in  the 
case  of  the  natives  it  is  as  a  rule  more  rapid.  The  primary 
lesions  are  often  not  noticed,  the  secondary  eruptions  are  very 
transitory  or  absent  altogether,  the  maculous  syphilides  are 
not  recognised  on  the  coloured  skin,  and  tertiary  symptoms 
make  their  appearance  very  early.  The  reason  why  the  con- 
tagion is  so  severe  among  the  inhabitants  of  tropical  regions  is 
probably  because  the  hygienic  surroundings  of  the  natives  leave 


CLIMATE,  RACE  AND  NATIONALITY       189 

very  much  to  be  desired  and  because  a  rational  treatment  of 
the  disease  is  unknown. 

It  was  formerly  believed  that  the  negro  race  is 
immune  against  syphilis.  Livingstone  who  in  the  middle 
of  the  last  century  found  Bechuanaland  as  yet  free  from 
the  disease  whilst  among  the  mixed  races  of  the  Korans 
and  Griquas  it  was  as  prevalent  as  in  Europe,  made  the 
assertion  that  syphilis  does  not  attack  the  full-blooded 
negro,  and  that  it  appears  the  more  frequently  in  mixed 
races  the  more  European  blood  flows  in  their  veins. 
Circumstances  have  however  materially  changed  since 
then  in  Africa.  Syphilis  has  with  the  increase  of  trade 
in  the  last  50  years  made  enormous  progress  in  the 
dark  continent,  and  even  the  natives  of  Bechuanaland 
who  were  at  one  time  quite  free  from  the  disease  suffer 
from  it  now  to  a  very  great  extent. 

Gonorrhoea  has  a  universal  distribution,  but  is  hardly  in 
any  way  different  in  different  races  and  climates  than  it  is  in 
Europe,  both  in  its  form  and  its  consequences.  It  is  often  main- 
tained that  gonorrhoea  is  mild  in  the  tropics;  other  observers 
think  it  is  more  virulent;  on  principle  such  a  differentiation  is 
not  justified.  It  is  probably  the  attention  given  to  the  disease 
and  the  manner  of  its  treatment  which  constitute  the  principal 
factors  that  determine  the  course  of  gonorrhoea ;  the  same  may 
be  said  with  regard  to  the  dietetic  observance,  particularly  the 
abuse  of  alcohol.1 

Distribution  of  tuberculosis. — It  is  well  known 
that  tuberculosis  is  prevalent  all  over  Europe.2  It  is  only  in  a 
few  places  and  under  special  circumstances  that  a  deviation 
from  the  generally  high  mortality-figure  occurs.  It  is  reported 
f .  i.  that  the  disease  is  rare  in  the  North- West  European  islands, 
in  Iceland,  Faroe,  the  Shetlands,  the  Hebrides,  and  in  the  North 


'Translator's  note :  I  was  recently  informed  by  two  gentlemen  from 
South  America  whom  I  treated  for  post-gonorrhceal  stricture  that  this  sequela 
is  exceedingly  frequent  there  on  account  of  the  very  strong  remedial  injections 
employed. 

*Hirsch,  Handbuch  d.  histor.-geogr.  Pathol.,  1886. — Herm.  Weber,  Munch, 
med.  Woch.,  1891. 


190  HEALTH,  DISEASE,  MARRIAGE 

of  Norway;  it  is  also  said  that  Cyprus  is  almost  free  from 
tuberculosis. 

In  the  United  States  of  America  tuberculosis  is  as  preva- 
lent as  in  Europe.  The  women  show  a  larger  mortality  because 
being  more  confined  to  their  homes  they  are  more  subjected  to 
the  contaminated  air  containing  the  products  of  the  expectora- 
tion.— In  Central  America  the  coasts  of  Mexico  and  especially 
the  towns  Vera  Cruz  and  Tampico  in  the  East,  and  Guayama 
and  Mazatlan  in  the  West,  as  well  as  the  coasts  of  the  Yucatan 
peninsula,  of  Mosquito  and  Panama  are  afflicted  with  rapidly 
progressing  forms  of  consumption,  as  is  also  Lima  on  the  coast 
of  Peru.  On  the  other  hand  the  highlands  of  the  Andes  in 
Peru  and  the  high  plains  of  Mexico,  Bolivia  and  Venezuela 
are  more  or  less  free  from  consumption. 

The  coast-lands  of  the  Argentine  Republic  and  those  of 
Brazil  are  said  to  have  been  formerly  quite  free,  but  are  greatly 
affected  now  since  the  population  has  increased  considerably 
and  many  large  towns  have  sprung  up.  On  the  other  hand  the 
villages  and  towns  of  the  Cordilleras  and  their  spurs  enjoy  as 
yet  a  certain  amount  of  immunity.  In  British  Guiana  also  the 
disease  is  assuming  larger  proportions.  A  great  difference  is 
noticeable  there  in  the  course  of  the  illness;  in  the  negroes  it 
is  very  rapid  and  takes  the  form  of  a  cheesy  pneumonia, 
whereas  in  the  coolies  it  is  much  slower  and  assumes  more  a 
catarrhal  and  peri-bronchial  character. 

In  Egypt  consumption  is  rarely  seen  in  the  interior  and 
especially  in  the  desert,  but  it  is  very  frequent  in  the  coast- 
towns  such  as  Alexandria.  In  Algeria  it  is  not  very  prevalent 
but  neither  is  it  altogether  rare.  It  is  said  that  the  Kabyli 
remain  free  from  the  disease  so  long  as  they  lead  a  nomad 
life.  In  the  west  of  Africa  tuberculosis  is  prevalent  in  many 
parts,  near  the  sea  as  well  as  inland;  the  coast  of  Senegambia 
seems  to  make  a  striking  exception.  On  the  high  table-land  of 
South  Africa  the  disease  is  rare. 

This  applies  also  to  German-South-West-Africa,  so 
that  Katz  has  made  the  Utopian  proposal  that  labour- 
colonies  of  work-people  suffering  from  the  disease  in 
its  early  stages  be  formed  there  as  a  remedy  for  the 


CLIMATE,  RACE  AND  NATIONALITY       191 

sufferers  and  as  a  means  of  raising  the  condition  of  the 
country. 

In  the  East  of  Africa  the  disease  is  frequent  and  generally 
rapid  in  its  course,  and  the  same  may  be  said  with  regard  to 
the  islands  of  Mauritius,  Reunion  and  Madagascar.  The  same 
conditions  prevail  in  the  Polynesian  islands,  especially  in  the 
Sandwich  group,  and  in  most  of  the  islands  of  the  Indian 
Archipelago.  In  New  Guinea  pulmonary  tuberculosis  is  either 
rare  or  as  a  rule  imported. 

On  the  high  plains  of  Armenia,  on  the  Syrian  coast  and  on 
the  high  table-land  of  Persia  consumption  is  relatively  rare; 
in  India  it  is  not  so  prevalent  as  in  the  temperate  latitudes  of 
the  Eastern  hemisphere,  but  it  does  occur  and  it  generally  runs 
?n  exceedingly  virulent  course,  like  in  the  other  regions  of 
Eastern  Asia  which  are  tropically  situated,  namely  Ceylon, 
Further  India,  and  especially  in  Cochin-China,  in  China  and 
Japan.  On  the  other  hand  tuberculosis  is  exceedingly  rare  in 
the  high  plains  of  the  Ghauts  situated  at  an  altitude  of  1500 
2000  meters,  on  the  Nilgiri  hills,  and  on  the  slopes  of  Himalaya. 

Australia  was  formerly  reputed  to  be  highly  immune,  but 
has  lost  now  this  reputation,  and  it  seems  that  the  disease  is 
constantly  becoming  more  frequent  among  the  increasing  popu- 
lations of  the  Australian  coasts. 

Climatic  conditions  alone  without  regard  to  other  and  espe- 
cially social  relations  do  not  offer  a  sufficient  explanation  of  the 
immense  distribution  of  tuberculosis.  The  temperature  does 
exercise  a  modifying  influence,  but  is  not  the  principal  factor; 
neither  cold  alone  nor  heat  alone  can  produce  consumption,  for 
there  are  regions  both  in  the  frigid  and  in  the  torrid  zones 
which  possess  a  high  degree  of  immunity,  and  others  which  are 
severely  affected.  It  is  very  probable  that  the  humidity  of  the 
air  is  of  injurious  influence.  The  cause  of  the  disease  is  in  tropi- 
cal and  sub-tropical  countries  as  a  rule  much  more  rapid  than 
in  the  temperate  and  the  cold  zones;  it  has  also  been  pointed 
out  that  consumption  exhibits  in  hot  countries  an  acute  and  sub- 
acute  character,  and  in  cold  and  temperate  regions  one  of  a 
more  chronic  nature. 

An  almost  universally  recognised  principle  is  that  the  eleva- 


192  HEALTH,  DISEASE,  MARRIAGE 

tion  of  the  soil  above  the  level  of  the  sea  exerts  a  great  influ- 
ence on  the  frequency  of  consumption.  As  evidence  of  this  we 
have  the  rarity  of  tuberculosis  in  the  Peruvian  Andes,  on  the 
high  plains  of  Mexico,  Bolivia,  Guatemala,  Salvador,  New- 
Granada,  and  on  the  Rocky  Mountains.  In  the  higher  regions 
of  Guiana  the  disease  is  seldom  seen,  whereas  in  the  valleys  it 
is  terribly  destructive.  The  same  may  be  said  of  Abyssinia, 
of  the  elevated  points  in  Armenia,  Persia,  East-India,  etc. 

Negroes  are  said  to  be  more  inclined  to  fall  a  prey  to  con- 
sumption than  any  other  races,  and  it  is  also  said  that  the  dis- 
ease runs  in  their  case  a  more  rapidly  fatal  course.  It  is  ques- 
tionable whether  this  condition  is  due  to  a  peculiar  constitutional 
anomaly  or  whether  it  is  insanitary  housing  accommodation,  in- 
sufficient nourishment  and  the  whole  mode  of  life  which  are 
responsible  for  it.  The  same  causes  may  apply  with  reference 
to  the  higher  susceptibility  of  some  nations  in  comparison  to 
others,  which  we  occasionaly  hear  of. 

Of  importance  are  the  experiences  that  large  tracts  which 
were  more  or  less  free  from  consumption  before  they  were 
colonised,  showed  an  increasing  mortality  from  this  disease 
after  being  opened-up,  as  f.  i.  the  United  States  of  North 
America,  Brazil  and  Australia.  In  the  first  instance  it  is  the 
tubercle  bacillus  of  which  we  must  think  in  this  connection; 
but  then  we  must  also  not  forget  that  where  large  numbers  of 
people  who  have  to  struggle  for  their  daily  bread  congregate 
and  where  they  are  obliged  to  live  under  unsatisfactory  condi- 
tions and  without  sufficient  food,  powerful  etiological  factors 
are  created  which  cannot  fail  to  materially  assist  in  the  spread 
of  consumption. 

It  is  not  the  purpose  of  this  work  to  discuss  the  unfavour- 
able social  conditions  and  other  evils,  and  as  regards  the  recipro- 
cal relation  between  marriage  and  consumption  the  reader  is 
referred  to  the  special  chapter  in  this  Manual  dealing  with 
the  subject. 

Anthropological  observations. —  In  the  conception 
and  among  the  customs  of  national  life,  marriage  plays  one 
of  the  most  important  parts  with  respect  to  its  preliminaries, 
preparatory  steps  and  consummation  on  the  one  hand,  and  on 


CLIMATE,  RACE  AND  NATIONALITY       193 

the  other  with  regard  to  married  life  and  the  duties  allotted 
to  married  individuals,  in  view  of  such  contingencies  as  preg- 
nancy, labour,  child-bed,  and  the  rearing  of  children.  We  sec 
these  vital  processes  surrounded  by  the  most  wonderful  prod- 
ucts of  the  imagination,  from  the  simplest  and  even  crudest 
psychical  emotions  to  the  highest  possible  poetical  glorification. 
Tradition  and  religious  belief  have  here  the  greatest  scope. 
Those  who  wish  for  more  detailed  information  on  the  point  may 
with  advantage  consult  the  perfect  work  of  Ploss-Bartels:  "Das 
Weib  in  der  Natur-  und  Volkerkunde"  which  is  one  of  the 
gems  of  German  literature.  Here  I  will  only  give  a  short 
summary  of  the  anthropological  studies  in  so  far  as  they  relate 
to  the  human  body  and  not  to  the  psychical  existence  of  man. 

Marriage  is  a  psychological  factor  which  is  necessary  for 
the  physical  welfare  of  man  as  well  as  of  woman.  So  long  as 
there  are  no  morbid  influences,  no  moral  or  material  troubles  to 
contend  against,  the  bodily  appearance  of  married  men  and 
women  always  improves  in  consequence  of  their  regular  mode 
of  life;  the  commencement  of  senile  decay  is  materially  post- 
poned. It  is  a  well-known  fact  proved  by  statistics  that  mar- 
riage has  a  beneficial  influence  on  the  duration  of  life. 

Celibacy. — The  modern  institutions  of  society  as  con- 
stituted in  our  present-day  civilised  States  where  marriage  is 
subject  to  certain  formalities  make  it  possible  for  man  to  gratify 
his  sexual  desires  without  coming  into  conflict  with  established 
arrangements.  For  this  reason  celibacy  in  man  is  not  physically 
so  discernible  as  in  the  female  sex.  The  so-called  "old 
bachelor"  may  in  the  course  of  time  also  acquire  certain  physical 
or  more  often  moral  peculiarities,  but  they  are  far  more  promi- 
nent in  the  "old  maid." 

In  the  unmarried  girls  of  the  German  nation  the  loss  of 
freshness  begins  on  an  average  in  the  27th  or  28th  year;  but 
often  the  first  signs  of  the  transformation  become  visible  at 
the  even  earlier  age  of  25,  and  once  started  it  goes  steadily 
forwards.  Anatomically  speaking,  the  rosy  colour  of  the  cheeks 
disappears  gradually,  the  skin  becomes  softer,  the  lips  pale 
and  thin,  the  naso-labial  fold  sharply  pronounced.  Deep 
shadows  form  under  the  eyes,  the  latter  acquire  a  dull  lustre 


194  HEALTH,  DISEASE,  MARRIAGE 

and  sorrowful  expression.  The  voice  receives  a  sharp  by-sound. 
A  part  of  the  down  on  the  face  develops  into  short  but  distinct 
hairs.  The  adipose  tissue  of  the  integument  diminishes,  and 
this  is  especially  noticeable  in  the  breasts  which  become  smaller 
and  often  also  flaccid  and  pendulous;  on  this  account  the  neck 
appears  thin,  the  shoulders  more  pointed,  and  angular,  and  the 
upper  ribs  and  clavicles  become  more  prominent.  Moral  indis- 
position and  all  sorts  of  nervous  complaints  accompany  these 
conditions  very  frequently.  A  regulated  sexual  intercourse  such 
as  our  social  institutions  make  possible  for  woman  only  in  the 
form  of  marriage  would  act  like  a  perfect  source  of  youth. 
Thus  nature  has  her  fixed  laws  which  demand  their  due  with 
inexorable  severity. 

Among  uncivilised  nations  there  are  no  old  maids.  With 
them  it  would  be  something  unheard  of  for  a  sexually  mature 
girl  not  to  become  the  wife  of  some  man,  either  for  an  indefinite 
period  or  for  a  life-time. 

The  pelvis  and  its  organs  in  various  nation- 
alities.— In  view  of  the  importance  of  the  pelvis  and  the 
pelvic  organs  in  married  life  I  give  here  the  following  brief 
anthropological  notice : 

Apart  from  the  differences  which  exist  between  the  pelvis 
of  the  man  and  that  of  the  woman,  there  are  such  variations 
among  the  female  representatives  of  the  several  human  races 
that  next  to  the  types  of  skull  the  pelvis  has  become  to  ethno- 
graphers the  principal  organ  for  racial  differentiation.  As  a  rule 
the  individual  differences  agree  with  the  fluctuations  in  the 
physical  build. 

The  pelvis  of  the  European  woman  serves  as  the  starting 
point  and  normal  type  of  the  observations.  The  oval  form 
should  be  peculiar  to  the  Caucasians,  the  quadrilateral  to  the 
Mongolians,  the  round  to  the  Americans,  and  the  cuneiform  to 
the  Negroes.  (Weber.}  Martin  has  the  following  group: 
I,  Pelvis  with  wide  inlet,  in  which  the  conjugate  is  almost  as 
long  as  the  oblique  diameter,  and  at  the  utmost  by  i/io  smaller 
than  the  oblique  diameter;  this  is  the  case  in  the  Bushwoman, 
the  Malay,  Javanese,  the  generality  of  American  and  Aus- 
tralian aborigines,  and  the  aborigines  of  the  islands  in  the 


CLIMATE,  RACE  AND  NATIONALITY       195 

Indian  and  Pacific  oceans;  II,  Pelvis  with  oblique-oval  inlet,  in 
which  the  conjugate  is  more  than  i/io  of  its  length  shorter 
than  the  oblique  diameter.  This  is  the  average  form  of  pelvis 
in  the  Caucasian  women,  and  that  in  the  African  negresses 
approaches  it  in  shape.  With  the  increase  in  the  oblique 
diameter  the  capacity  of  these  pelves  grows;  in  this  respect 
English-women  are  said  to  excel  physically  and  according  to 
Litzmann's  measurements  Holstein  women  come  next. 

The  pelves  of  Jewesses  in  Dorpat  are  according  to 
Schroeter  very  small. — Gutierrez  says  that  the  pelvis 
in  Mexican  women  is  small  and  especially  narrow 
towards  the  outlet. 

Further  peculiarities  of  the  pelvis  are  to  be  found  in  differ- 
ences which  exist  in  the  size,  thickness  and  position  of  the  iliac 
bones.  The  wedge-shaped  and  longer  pelvis  of  the  negress  sug- 
gests the  pelvis  of  animals.  Other  pelvic  bones  are  also  said  to 
possess  characteristic  racial  differences.  The  width  of  the  base 
of  the  sacrum  reaches  its  maximum  in  the  white  race,  especially 
in  European  women,  after  them  come  the  yellow  races  and 
finally  the  black.  The  height  of  the  sacrum  varies  from  six 
vertebrae  in  the  African  negroes  to  five  in  the  Europeans.  The 
curvature  of  these  bones  is  most  marked  in  the  white  races, 
especially  the  Europeans,  then  follow  the  yellow  races,  and  the 
flattest  sacra  are  seen  in  the  negroes. — The  angle  of  inclination 
of  the  pelvis  to  the  vertebral  column  is  also  variable  in  size. 

There  is  no  doubt  that  the  mode  of  life,  as  well  as  customs 
and  habits  have  a  certain  influence  on  the  prevailing  form  of 
pelvis.  Of  the  greatest  importance  is  above  all  the  nutrition 
of  the  skeleton  as  a  whole  and  the  supply  of  bone-forming 
material.  The  kind  of  dress  generally  in  use  may  have  some 
effect  upon  the  pelvis,  especially  when  it  is  growing,  in  mechanic- 
ally altering  its  shape,  and  the  same  result  may  arise  from  pro- 
longed attitudes  of  the  body  in  certain  positions  or  from  some 
special  form  of  activity.  The  manner  of  carrying  their  children 
on  the  buttocks  as  practised  f.  i.  by  negresses  may  be  the  cause 
of  lordosis  of  the  spine  and  of  a  secondary  displacement  of  the 
pelvis. 

Besides  the  bony  frame  of  the  pelvis  it  is  the  larger  or 


196  HEALTH,  DISEASE,  MARRIAGE 

smaller  amount  of  fatty  connective  tissue,  which  varies  so  much 
quantitatively  in  the  different  nations,  that  determines  the  form 
of  the  female  hips.  The  latter  together  with  the  development 
of  the  thighs,  calves  and  shoulders  constitute  the  general  appear- 
ance of  woman  which  we  designate  generally  as  figure. 

The  fatty  connective  tissue  of  the  gluteal  region 
shows  quantitatively  many  variations,  by  which  the 
external  appearance  is  naturally  altered.  Australian 
women  are  markedly  deficient  in  fat ;  on  the  other  hand 
they  exhibit  occasionally  such  an  increase  of  the  same 
that  it  leads  in  extreme  cases  to  fatty  buttocks  or  steato- 
pygia,  a  condition  peculiar  to  Bushwomen  and  Hot- 
tentot-women, and  regarded  by  them  as  a  sign  of 
beauty. 

As  regards  the  genital  organs  proper  there  also  exist  special 
peculiarities.  The  vulva  may  be  situated  either  somewhat 
higher  as,  according  to  Columbat,  it  is  the  case  in  French 
women,  Spaniards,  Italians  and  in  the  South  generally,  or  less 
anteriorly  as  in  English  and  Dutch  women;  in  Australian 
women  also  the  pudenda  are  situated  more  posteriorly.  The 
size  of  the  introitus,  the  direction  and  length  of  the  vagina  are 
subject  to  considerable  variations.  Especially  multifarious  are 
the  larger  and  smaller  labia ;  lax,  more  or  less  adipose,  of  small 
or  considerable  size,  the  latter  reaching  sometimes  enormous 
proportions,  as  f.  i.  the  so-called  "Hottentot  apron,"  an  hyper- 
trophic  development  of  the  labia  minora  probably  of  artificial 
origin.  The  size  of  the  clitoris  also  varies  from  rudimentary 
proportions  to  considerable  dimensions  which  are  likewise  pro- 
duced frequently  by  artificial  irritation. 

Racial  differences  with  regard  to  the  internal  female  genital 
organs  have  hitherto  not  been  noticed,  and  considering  that 
their  functions  are  everywhere  alike  such  differences  probably 
do  not  exist. 

The  female  breasts. — The  female  breasts  in  their 
youthful  freshness  have,  as  is  well-known,  inspired  the  poets 
of  all  times  with  highly  rapturous  sensations.  As  a  matter  of 
fact  they  take  among  the  secondary  sexual  characteristics  the 
principal  place,  and  we  can  judge  from  many  songs  what 


CLIMATE,  RACE  AND  NATIONALITY       197 

demands  the  aesthetic  taste  of  the  various  nations  have  made 
on  the  ideal  form  of  this  physical  organ. 

In  speaking  of  the  racial  form  of  the  female  breast  one 
does  not  generally  think  of  it  as  it  appears  during  child-bed 
or  lactation,  or  when  undergoing  the  changes  brought  about  by 
advancing  age,  but  of  the  youthful  and  virgin  organ  of  sexually- 
mature  young  girls  at  their  best  age.  Considerable  varieties  of 
form  are  here  noticed  in  different  races.  Sometimes  the  nipple 
is  small  and  flat  like  a  little  button,  sometimes  more  massive 
and  of  conical  shape  with  a  broad  base  and  rounded  point, 
sometimes  large  and  cylindrical,  almost  like  a  finger.  Like  the 
nipples,  the  areolae  also  show  considerable  differences;  some- 
times they  are  pale,  and  sometimes  dark-red,  sometimes  brown 
and  even  almost  black  in  colour;  sometimes  they  form  small 
and  sometimes  large  and  even  enormous  surfaces;  sometimes 
they  project  lightly  and  sometimes  prominently  like  half- 
spheres  from  the  curvature  of  the  breasts,  and  sometimes  they 
are  separated  from  the  latter  by  a  pronounced  circular  con- 
stricting furrow. 

It  is  possible  that  the  different  human  races  possess 
ethnographically  well-marked  characteristics  in  regard 
to  the  form  of  the  female  breast,  and  that  the  organ 
has  undergone  modifications  under  the  influence  of  the 
mixture  of  races  or  nations.  Hitherto  no  conclusive 
observations  have  been  made  on  the  point.  But  in 
order  to  fill  up  the  gap  for  future  observers  I  give  here 
the  following  plan  according  to  Ploss-B artels :  In 
regarding  the  curvature  of  the  breasts  we  should  notice 
whether  they  spring  more  or  less  immediately  from  the 
surface  of  the  chest,  or  whether  the  latter  begins  from 
the  clavicles  downwards  to  gain  in  fatty  connective 
tissue  and  to  pass  imperceptibly  into  the  glands.  The 
manner  of  their  situation  should  be  taken  into  considera- 
tion, whether  they  are  placed  higher  up  or  lower  down 
on  the  thorax,  whether  they  take  their  origin  nearer  to 
the  median  line  or  nearer  to  the  axilla.  Of  special 
importance  is  the  consideration  of  their  size  (strong  or 
massive,  full,  moderate,  weak,  small  or  sparse),  their 


198  HEALTH,  DISEASE,  MARRIAGE 

consistency  (standing,  inclining,  hanging),  form  and 
shape  (saucer-like,  semi-spherical,  conical,  goat-udder- 
like). 

Physiology  has  given  us  proofs  that  the  breasts  belong  to 
the  sensual  organs.  The  touch  and  gentle  irritation  of  the 
mammary  nerves  are  capable  of  producing  by  reflex  action 
contractions  in  the  uterine  muscles,  and  in  this  way  a  pleasurable 
sensation  in  the  entire  organism.  During  sexual  excitement  the 
breasts  swell  and  the  nipples  become  stiff  and  erect.  After  con- 
ception and  child-birth  the  breasts  have  quite  a  different  signifi- 
cation for  both  mother  and  child. 

The  anatomical  changes  in  the  form  which  the 
organs  show  after  lactation  where  they  appear  as  more 
or  less  flaccid  and  lax  cutaneous  attachments,  with 
wrinkled  surfaces  and  discoloured  areolae  are  manifest 
in  barbarous  nations  in  many  different  ways.  Whereas 
among  civilised  people  the  breasts  are  generally  covered 
up  and  assisted  by  various  kinds  of  support  to  obtain 
a  pleasing  form,  the  women  of  uncivilised  nations  are  in 
the  habit,  especially  in  hot  countries,  of  going  about 
half-naked,  and  their  ugly  skin-bags  hang  down  and 
away  from  the  chest  when  they  stoop  over  their  work, 
in  a  most  disfiguring  manner. 

Among  barbarous  nations  and  among  those  living  in  a  semi- 
civilised  state  it  is  quite  customary  for  the  mothers  to  suckle 
their  children,  and  it  is  unfortunately  the  women  of  the  most 
civilised  countries  who  neglect  this  duty  either  willingly  or 
because  of  the  physical  inability  of  the  mothers  to  fulfil  it.  This 
is  the  case  with  the  old  Hindus,  the  Japanese,  the  Chinese,  and 
above  all  with  the  European  nations,  and  chief  among  them 
the  Germans  and  the  French. 

Under  normal  physical  circumstances  it  is  usual  for  Euro- 
peans to  suckle  their  infants  for  about  a  year;  country-people 
and  also  town-proletarians  continue  it  sometimes  up  to  two  full 
years  and  even  longer;  a  lactation  of  2  to  3  years  is  practised 
by  many  women  mostly  out  of  Europe,  and  there  are  authentic 
reports  that  they  prolong  it  very  often  for  many  years,  even 
up  to  the  1 5th.  (Eskimos.)  The  reasons  for  this  are  on  the 


CLIMATE,  RACE  AND  NATIONALITY       199 

part  of  the  child  a  certain  feeling  of  satisfaction,  on  the  part 
of  the  mother  a  pleasurable  sensation.  The  general  opinion 
that  so  long  as  a  mother  suckles  her  child  she  runs  no  risk  of 
conceiving  has  also  something  to  do  with  the  matter. 

Prolificness. — Most  nations  in  the  world  desire  large 
families  and  the  fruitfulness  of  the  wife  is  regarded  as  a  special 
blessing  and  as  high  conjugal  bliss.  Sterility  on  the  other  hand 
is  looked  upon  as  an  imperfection  of  the  wife.  Where  the  evil 
cannot  be  removed,  where  it  is  not  possible  to  break  the  spell 
adhering  to  the  wife  or  to  appease  the  anger  of  the  deity,  the 
woman  is  often  turned  away.  As  to  the  cause  of  sterility  there 
existed  in  olden  times  and  exist  even  yet  among  barbarous 
nations  all  sorts  of  mystical  opinions,  but  the  recognition  is 
gradually  advancing  that  abnormal  physical  development  or 
diseased  conditions  in  the  wife  must  be  responsible  for  it. 

A  high  regard  for  fruitfulness  is  not  common  to  all 
nations ;  some  regard  it  even  as  something  contemptible 
and  animal-like  (Greenlanders).  In  Europe  also  and 
among  many  civilised  nations  generally  the  joy  at 
accessions  rapidly  following  one  another  is  very  small. 
— The  Roman  Emperor  Augustus  fixed  definite  penal- 
ties for  childlessness. — Unfruitfulness  is  considered  in 
the  Orient  as  a  disgrace  and  Mahometans  as  well  as 
the  Eastern  Jews  regard  it  as  a  ground  for  divorce. 
The  Turkish  woman  who  has  no  children  is  but  little 
respected.  Chinese  women  look  upon  large  families  as 
the  greatest  blessing.  The  nations  of  Africa  also  con- 
sider childlessness  as  a  disgrace. 

From  times  immemorial  endeavours  have  been  made  to 
counteract  unfruitfulness,  and  all  sorts  of  mysterious  procedures 
have  been  adopted,  such  as  medicines  and  mechanical  remedies, 
baths,  appeals  for  divine  help  in  many  forms  and  for  super- 
natural human  aid,  sympathetic  remedies,  the  invocation  of 
assistance  from  dead  persons,  etc. 

On  the  other  hand  there  are  occasions  when  temporary  or 
permanent  unfruitfulness  appears  to  be  desirable.  Preventive 
measures  of  various  sorts  have  been  recommended,  f.  i.  the 
interrupted  form  of  intercourse,  drugs  and  mechanical  appli- 


200  HEALTH,  DISEASE,  MARRIAGE 

ances,   etc.     They  are  employed  more  by  civilised  than  by 
uncivilised  nations. 

Considerable  differences  exist  in  the  fruitfulness  of  different 
races,  and  occasionally  it  is  possible  to  discover  the  causes  by 
which  these  differences  are  produced.  For  details  the  reader  is 
referred  to  the  work  of  Ploss-Barteh. 

If  there  happens  to  be  in  two  nations  of  different  races,  a 
difference  in  the  degree  of  their  fruitfulness  it  does  not  by  any 
means  follow  that  a  racial  distinction  is  present.  For  closer 
investigation  shows  that  greater  or  smaller  fruitfulness  depends 
greatly  from  a  number  of  other  factors  as  well.  One  of  these 
is  the  moral  condition  of  the  population,  its  social  state  and 
associated  with  it  the  relative  ages  of  the  procreators  to  one 
another.  One  may  doubtless  regard  as  a  favourable  sign  of  the 
well-being  of  a  nation  its  constant  increase  by  means  of  a  grow- 
ing number  of  legitimately-born  children ;  on  the  other  hand  a 
gradual  decrease  in  the  latter  is  a  sure  indication  of  a  morbid 
state  of  morality  or  of  social  and  political  decay.  We  have 
evidence  of  this  in  the  stagnant  development  of  the  French 
population. 

It  has  been  ascertained  that  marriages  are  most  fruitful 
when  husband  and  wife  are  of  the  same  age  or  when  the  hus- 
band is  from  one  to  six  years  older  than  the  wife.  Quetelet 
summarised  the  results  of  the  observations  on  the  influence  of 
age  upon  the  number  of  births  as  follows:  Early  marriages 
favour  sterility;  from  the  33d  year  in  the  man  and  the  26th  in 
the  woman  fruitfulness  begins  to  diminish ;  at  about  this  period 
it  reaches  the  highest  point.  The  difference  in  the  ages  of  the 
procreators  depends  of  course  partly  also  on  the  earlier  or  la*ter 
beginning  of  puberty,  and  also  on  climatic  elements. 

It  is  known  that  in  the  Southern  countries  with 
Latin  populations  marriages  are  as  a  rule  entered  earlier 
into  than  in  the  North,  partly  on  account  of  the  earlier 
appearance  of  physical  and  social  maturity  among  the 
inhabitants  of  the  former,  and  partly  because  generally 
speaking  there  is  not  so  much  wanted  there  to  establish 
a  household  and  to  maintain  a  family,  and  a  livelihood 
is  more  easily  gained  than  in  Northern  countries. 


CLIMATE,  RACE  AND  NATIONALITY       201 

Moreover  almost  all  Southern  nations  are  more  inclined 
towards  matrimony  than  the  more  careful  and  circum- 
spect Northerners,  especially  of  Germanic  Europe.    It 
is  consequently  not  so  much  race  and  climate  as  a  state 
of  civilisation  brought  about  by  conditions  of  develop- 
ment based  on  an  historical  foundation,  and  the  mode 
of  life  regulating  the  sexual  relations,  which  are  the 
decisive  factors.    This  accounts  for  the  fact  that  differ- 
ent nationalities  living  in  the  East  under  the  same  cli- 
matic conditions  exhibit  different  degrees  of  fruitfulness. 
Thus  Damian  Georg  wrote  about  the  nations  living  in 
Greece,  that  the  Jews  and  Armenians  there  are  very 
fruitful,  the  Greeks  less  so,  and  the  Turks  least  of  all. 
It  is  reported  that  in  the  United  States  the  women 
in  the  5th  and  6th  generations  become  gradually  paler 
and  thinner.    It  is  a  fact  that  the  number  of  births  in 
North  America  is  diminishing;  the  disinclination  of  the 
American  women  to  assume  the  obligations  of  mother- 
hood is  not  unconnected  with  this  diminution. 
The  fruitfulness  of  European  families  emigrating  to  the 
tropics  diminishes  and  a  constant  supply  of  fresh  European 
blood  is  advisable  for  the  purpose  of  keeping  that  fruitfulness 
alive. 

It  is  also  to  be  taken  into  consideration  that  favourable 
circumstances  exert  in  every  population  a  great  influence  on  the 
procreation  of  descendants,  but  that  numerous  incidents  such 
as  the  overburdening  of  the  female  sex  and  the  frequent  abor- 
tions resulting  in  consequence,  premature  marriages,  the  preva- 
lence of  certain  diseases,  debilitating  habits  of  the  male  sex,  etc. 
tend  to  prevent  a  great  Increase  in  the  number  of  births.  This 
is  probably  also  the  cause  of  the  relatively  smaller  fruitfulness 
shown  by  some  nations. 

Accidental  miscarriages. — Not  a  few  nations  of 
the  earth  suffer  greatly  from  natural  miscarriages.  In  very 
many  cases  the  reason  is  to  be  looked  for  in  an  irrational  mode 
of  life,  and  among  uncivilised  nations  to  a  great  extent  in  the 
over-burdening  of  the  women. 

Thus  the  cause  of  the  remarkable  unfruitfulness  in 


202  HEALTH,  DISEASE,  MARRIAGE 

New-Zealand  lies  not  only  in  the  infanticide  prevalent 
there,  but  also  probably  in  the  severe  manual  labour 
which  the  women  have  to  perform,  and  in  the  hard- 
ships connected  with  their  nomadic  life.  De  Rochebrune 
says  that  miscarriages  occur  very  frequently  among  the 
Woloffs,  principally  on  account  of  the  hard  life  which 
their  women  lead  and  because  in  addition  to  their  house- 
duties  they  go  on  for  hours  at  a  stretch  crushing  millets, 
a  very  laborious  and  fatiguing  occupation ;  they  are  also 
in  the  habit  of  carousing  all  through  the  night  when 
they  execute  to  musical  accompaniment  exciting  and 
obscene  dances  of  which  rotation  of  the  pelvic  region 
is  a  distinguishing  feature. 

A  certain  physical  predisposition  of  such  nations  to  miscar- 
riages must  be  presumed,  for  other  barbarous  tribes  suffer  very 
little  from  them  though  their  women  also  work  very  hard,  and 
during  pregnancy  too.  This  is  for  instance  the  case  among  the 
lower  classes  in  China  where  women  are  employed  in  the  very 
laborious  occupation  of  rowers,  whilst  the  rich  Chinese  ladies 
exhibit  a  great  inclination  to  miscarriages  on  account  of  their 
mode  of  living ;  the  mutilation  of  their  feet  forces  them  to  lead 
a  sedentary  life  and  occasions  in  them  an  absence  of  resisti- 
bility.  In  Persia  though  the  women  are  in  the  habit  of  riding 
on  horseback  in  the  same  way  as  men,  even  when  they  are 
pregnant,  natural  miscarriage  is  very  rare. 

As  a  cause  of  miscarriages  we  may  also  mention  a  certain 
kind  of  manual  treatment  which  pregnant  women  undergo 
among  some  nations,  f.  i.  the  kneading  of  Mexican  women  in 
the  yth  month,  a  special  sort  of  massage  employed  by  the 
Javanese,  similarly  the  custom  of  very  hot  baths  as  practised  in 
Turkey,  etc. 

The  influence  of  a  strange  climate  has  also  been  accused 
of  being  an  occasional  cause  of  miscarriage,  perhaps  less  on 
account  of  the  high  temperature  than  of  the  malaria  so  gen- 
erally prevalent.  Acclimatised  individuals  are  less  threatened 
than  new  arrivals.  Among  the  natives  of  Cayenne  and  Guiana, 
miscarriage  is  rare,  but  it  is  more  frequent  among  European 
women  who  arrive  there  in  a  condition  of  pregnancy  or  who 


CLIMATE,  RACE  AND  NATIONALITY      203 

become  pregnant  after  a  short  sojourn.  In  the  Nile  countries 
also  European  women  frequently  abort;  so  they  do  when  living 
in  India  during  the  hot  season ;  the  same  thing  is  reported  with 
regard  to  the  tropical  parts  of  Brazil. 

Of  European  women  it  is  generally  supposed  that  French- 
women are  exceedingly  predisposed  to  miscarriages  perhaps 
because  of  the  frequency  with  which  they  bathe  and  on  account 
of  the  anomalies  which  their  genital  organs  present  very  often. 
Premeditated  abortion. — It  is  not  correct  to  regard 
artificial  abortion  as  a  morbid  excrescence  of  civilisation, 
inasmuch  as  semi-civilised  nations  and  even  many  barbarous 
ones  practise  it  as  well.  We  may  conclude  from  this  on  the 
one  hand  that  the  unborn  child  is  considered  of  very  little 
value,  and  on  the  other  that  the  danger  of  abortion  to  the 
mother  are  not  thought  to  be  very  great. 

It  is  worth  mentioning  that,  according  to  Scherzer, 
the  natives  in  New-South-Wales  are  gradually  dying  off 
because  abortion  is  so  prevalent  among  them.  It  is 
practised  by  barbarous  nations  on  account  of  the  diffi- 
culties connected  with  the  bringing-up  of  children.  The 
privations  and  tortures  which  the  native  Australian 
women  have  to  suffer  during  pregnancy  and  labour  are 
such  that  they  prefer  to  avoid  the  results  of  pregnancy. 
Of  the  female  inhabitants  of  New-Caledonia,  Samoa, 
Tahiti  and  Hawaii  it  is  reported  that  they  practise 
abortion  for  the  purpose  of  preventing  their  breasts 
from  becoming  flabby  and  lax.  In  the  Malay  Archi- 
pelago emmenagogues  are  much  in  use  without  causing 
any  lasting  inconvenience  to  the  bodies  of  the  women. 
Stevens  reports  that  in  one  portion  of  Malakkha  abor- 
tion is  abhorred,  and  in  another  generally  practised 
for  the  purpose  of  escaping  the  work  caused  by  the 
growing  child;  if  a  married  woman  is  found  out  to  have 
induced  abortion,  her  husband  is  allowed  to  punish  her 
severely  with  a  club.  Infanticide  is  rare  in  Borneo 
because  it  is  anticipated  by  abortion.  "In  no  country  in 
the  world,"  says  Allan  Webb  of  Calcutta,  "are  infanti- 
cide and  abortion  so  frequent  as  in  India,  and  though 


204  HEALTH,  DISEASE,  MARRIAGE 

the  English  Government  has  succeeded  in  putting  a  stop 

to  the  murder  of  newly-born  children,  it  is  powerless 

to  prevent  abortions,  which  have  caused  and  still  cause 

the  death  of  many  a  mother."     On  account  of  the 

facility  and  impunity  of  artificial  abortion  there  are  no 

illegitimate  children  in  the  Orient,  but  even  among  the 

better  classes  it  is  no  rare  thing  in  Constantinople,  f.  i. 

for  married  people  to  procure  abortion  when  they  have 

already  two  children,  including  a  boy.    A  considerable 

number  of  African  nations  practise  abortion;  thus  the 

Egyptian  and  Algerian  women;  there  are  in  Algiers 

Jewesses  who  carry  on  the  practice  in  booths  in  public 

places.     Whilst  a  few  of  the  North-American  Indian 

tribes  abhor  abortion,  many  others  are  almost  extinct 

owing  to  the  prevalence  of  the  practice  among  them. 

It  is  well  known  that  among  the  whites  of  North  America 

abortion  is  very  much  in  vogue,  and  that  especially  in  the  large 

towns  of  the  United  States  there  are  special  institutions  where 

girls    and   women    can   undergo    premature    confinement;    all 

American  newspapers  contain  public  announcements  respecting 

such  places  of  ill-repute.  Women  do  not  see  anything  immoral 

in  telling  casual  acquaintances  that  they  did  not  wish  to  have 

any  children  and  that  they  journey  to  St.  Louis  or  New  Orleans 

for  the  purpose  of  procuring  abortion.    In  Europe  also  the 

practice  seems  to  gain  in  favour.  We  know  at  the  present  time 

much  more  about  the  matter  in  so  far  as  it  relates  to  numerous 

foreign  countries,  than  as  to  what  takes  place  nearer  home. 

By  far  the  most  frequent  and  most  usual  cause  of  abortion 
is  the  desire  to  remove  a  dishonouring  pregnancy;  next  to  it 
are  pecuniary  considerations.  Fashion  also  is  an  important  ele- 
ment, as  it  is  with  some  nations  against  established  custom  to 
have  children  in  the  first  year  or  two  after  marriage,  or  more 
than  one  or  two  children  altogether;  there  is  further  the  dis- 
inclination of  the  women  to  undergo  the  inconvenience  of  lacta- 
tion, or  the  troubles  of  bringing  up  children;  other  causes  are 
jealousy,  female  vanity  and  other  such  defects. 

It  is  therefore  seen  that  abortion  is  not,  as  it  is  frequently 
maintained,  a  result  of  degenerate  social  conditions  such  as 


CLIMATE,  RACE  AND  NATIONALITY       205 

constitute  the  drawbacks  of  a  state  of  civilisation.  The  evil  is 
older  than  civilisation;  for  the  perception  that  an  interference 
of  this  kind  is  wrong  makes  its  way  only  gradually  and  slowly 
in  the  conscience  of  a  people.  It  was  much  later  that  religious 
and  political  legislators  endeavoured  to  combat*the  destruction 
of  embryonic  life  by  regulations  and  threats  of  punishment. 
The  influence  of  the  criminal  law  however  has  hitherto  not 
been  powerful  enough,  and  those  concerned  in  the  matter 
have  devoted  far  too  little  attention  to  an  alteration  in 
the  social  circumstances  by  which  the  evil  could  be  removed 
(Ploss-Bartels). 


VI 

Sexual   Hygiene  in  Married  Life 


VI 

SEXUAL    HYGIENE   IN    MARRIED    LIFE 
By  Professor  P.  Fiirbringer  (Berlin) 

IN  dealing,  as  being  a  part  of  the  subject  of  this  treatise, 
with  the  question  how  the  sexual  intercourse  of  married  persons 
should  be  exercised  in  accordance  with  medical  opinion  that  is 
in  such  a  manner  as  not  to  prove  injurious  to  either  partner, 
this  article  is  intended,  in  the  first  instance,  to  provide  the 
medical  profession  with  a  guide  for  young  husbands;  husbands, 
because  it  is  they  who  are  the  controllers  of  the  act  and  who 
as  a  rule  play  the  more  active  part,  and  young,  because  those 
who  are  no  longer  so  have  by  experience  learned  how  to  correct 
their  early  mistakes. 

It  is  clear  that  where  the  main  object  is  how  to  prevent 
diseases  by  the  avoidance  of  errors  in  sexual  intercourse,  the 
diseases  as  such  cannot  form  part  of  the  subject  discussed. 
Hygiene  is  not  medical  treatment.  I  shall  therefore  confine 
myself  to  the  consideration  of  the  physiological  conditions  and 
of  those  lighter  disturbances  which  are  not  yet  regarded  by  the 
general  public  of  sufficient  importance  to  induce  those  numerous 
individuals  who  are  subject  to  them  to  seek  medical  advice.  If 
I  include  here  from  a  practical  point  of  view  the  predispositions 
to  disease  as  well,  I  can  do  no  more  than  barely  touch  occa- 
sionally the  fringe  of  the  vast  range  of  disease  proper,  and 
must  refer  for  further  elucidation  to  the  exhaustive  articles  of 
the  other  contributors  to  this  work.  Nevertheless — this  lies  in 
the  nature  of  the  subject — it  will  hardly  be  possible  to  avoid 
introducing  such  conditions  as  nervous  diseases,  diseases  of  the 
genital  organs  of  both  sexes,  or  pregnancy,  or  entering  into  the 
consideration  of  the  hygienic  significance  of  marriage. 

In  agreement  with  the  view  expressed  by  the  senior  Editor 


210  HEALTH,  DISEASE,  MARRIAGE 

of  this  work  under  the  third  heading,  with  regard  to  the  part 
played  by  the  sexual  intercourse  per  se  of  married  individuals, 
that  is,  in  the  absence  of  any  transmissible  disease,  there  arises, 
as  a  special  part  of  the  subject,  the  question  as  to  the  manner 
and  frequency  of  the  act  of  copulation  in  the  normal  life  of 
the  married  persons,  and  especially  during  menstruation,  preg- 
nancy and  child-bed  or  in  other  words  during  the  period  of 
involution.  Indissolubly  connected  with  this  subject  is  a  con- 
sideration of  the  different  methods  employed  to  prevent  con- 
ception, of  sexual  continency  and  of  some  general  hygienic 
measures  in  so  far  as  they  are  calculated  to  serve  the  interests 
of  a  correct  sexual  intercourse. 

The  literature  on  the  subject  from  this  point  of  view  is 
rather  scanty,  and  yet  if  looked  for  carefully  not  quite  so  poor 
as  it  is  generally  believed.  In  any  case  there  is  no  text-book 
treating  of  the  subject-matter  as  a  whole  to  serve  to  medical 
men  as  a  guide  and  for  reference.  Not  sufficiently  known  and 
appreciated  are  as  yet  three  lectures  by  the  Swedish  author 
Ribbing  entitled:  "Sexual  Hygiene  and  its  ethical  conse- 
quences1" a  work  full  of  lofty  sentiment  dealing  with  the  princi- 
pal points  of  the  subject  in  a  thorough  and  worthy  manner. 
Several  German  authors  have  also  devoted  considerable  atten- 
tion to  the  subject.  We  will  name  their  works  without  in  any 
way  detracting  from  the  value  of  other  more  general  observa- 
tions met  with  in  various  writings  without  any  references  to 
literature — and  of  these  there  are  a  great  many.  I  myself  have 
also  dealt  with  various  points  of  the  subject  in  my  article 
"Disturbances  in  the  sexual  functions  of  the  male  sex."2  The 
fairly  comprehensive  literature  given  there  has  to  a  great  extent 
been  made  use  of  in  connection  with  this  contribution,  and  the 
experiences  laid  down  on  the  former  occasion  will  be  materially 
amplified  in  these  pages. 

Regulation  and  performance  of  sexual  inter- 
course.— Beginning  with  the  technique  of  the  sexual  act  it 
is  no  use  denying  that  the  activity  of  the  physician  in  this 


*B.  Reyher,  Leipsic  1890.     (3d  edit.) 

'Nothnagel's  Spezielle  Pathologic  und  Therapie,  Vol.  19,  3d  part,  2d  edit. 
Vienna  1901. 


SEXUAL  HYGIENE  IN  MARRIED  LIFE      211 

direction  is  a  very  limited  one  indeed.  Not  very  often,  "but 
rather  seldom"  (v.  Schrenck-Notzing)  is  a  doctor  consulted 
before  the  consummation  of  arranged  marriages,  and  equally 
rarely  does  it  happen  that  the  husband  is  a  novice  in  the  matter. 
As  a  rule  he  knows  "how  it  is  done."  It  is  not  my  present  con- 
cern to  express  an  opinion  on  the  moral  justification  of  pre- 
connubial  intercourse  or  to  enter  into  a  discussion  on  the  extent 
to  which  public  opinion  under  our  present-day  civilisation  per- 
mits or  even  sanctions  the  practice.  Like  Ribbing,  Rubner  and 
other  authors  I  cannot  look  upon  it  as  a  desirable  object,  and 
still  less  as  a  remedy  to  be  recommended  by  the  practitioner. 
I  shall  presently  give  my  reasons  for  this  attitude.  Fortunately, 
moreover,  the  chaste  young  man  is  not  absolutely  extinct.  From 
observations  extending  over  many  years  among  private  patients 
and  also  in  hospital  practice  I  can  testify  to  this  being  the  case 
even  in  Berlin — that  metropolis  so  full  of  temptations.  If  one 
often  hears  "liaisons"  spoken  of  as  something  quite  natural, 
in  the  presence  of  the  parent  accompanying  the  patient,  who 
not  infrequently  even  confesses  to  having  advised  the  son  in 
that  direction,  there  are  still  a  certain  number  of  inexperienced 
young  men  left  whose  questions  to  the  doctor  are  downright 
sincere. 

There  is  always  a  certain  amount  of  "offensiveness"  in  the 
treatment  of  subjects  pertaining  to  the  sexual  functions.  But 
it  is  the  duty  of  the  medical  man  to  answer  conscientiously 
and  to  the  best  of  his  ability  questions  relating  to  health 
addressed  to  him  by  those  seeking  his  advice  and  it  is  even 
permissible  under  circumstances  to  exhibit  a  certain  inquisitive- 
ness  into  the  most  intimate  details  of  married  life.  He  is  but 
a  poor  doctor  who  cannot  make  his  patient  realise  that  idle 
curiosity  is  not  a  part  of  his  profession !  But  on  the  other  hand 
he  must  also  expect  occasionally  to  derive  pain  and  disgust 
from  the  revelations  made  to  him  at  his  instigation,  though 
rarely  so  in  the  case  of  newly-wedded  female  patients.  The 
authoress  Fischer-Duckelmann  is  perfectly  justified  in  calling 
attention  to  the  evil  consequences  often  resulting  from  a  neglect 
on  the  part  of  many  male  doctors  to  inquire  into  the  moral 
side  of  the  married  life  of  their  female  patients. 


212  HEALTH,  DISEASE,  MARRIAGE 

Position. — I  should  not  have  entered  into  the  question  of 
position  during  the  sexual  act  of  married  people  if  I  were  not 
convinced  from  a  perusal  of  the  many  contributions  on  the 
subject,  that  what  is  natural  is  not  always  obvious.  The  hygienic 
importance  of  the  position  in  which  the  act  is  exercised  most 
easily  and  most  agreeably  and  which  requires  least  muscular 
exertion  namely  the  horizontal  one  with  body  against  body, 
was  already  known  in  most  ancient  times  as  we  read  in  the 
work  of  Ploss  and  Bartels,1  and  this  position  has  been  handed 
down  to  us  by  pen  and  pencil  as  the  one  which  has  always 
been  generally  adopted.  That  it  is  the  woman  who  occupies  the 
lowermost  position  may  be  regarded  as  symbolical  of  the  lord- 
ship of  the  male  sex,  of  the  submission  of  the  weak  to  the  strong, 
unless  we  see  in  it  also  elements  of  shelter  and  protection.  Arid 
yet  natural  as  it  is,  this  question  of  position  frequently  necessi- 
tates special  words  of  advice  on  the  part  of  the  physician  as 
I  can  testify  from  personal  experience,  and  it  behoves  us  on 
such  occasions  to  be  plainly  outspoken.  Many  a  case  of  so-called 
male  impotency — and  I  allude  here  particularly  to  individuals 
affected  with  light  psychical  ailments,  congenital  or  acquired — 
is  nothing  but  inhibition  depending  entirely  or  to  a  great  extent 
upon  the  false  modesty  and  awkwardness  of  the  female  partner, 
and  could  soon  be  set  right  by  a  proper  medical  consultation  in 
her  presence.  And  how  often  do  otherwise  highly  intelligent 
young  husbands  confess  ignorance  as  to  whether  they  perform 
their  marital  duties  in  a  normal  manner?  It  is  under  such  cir- 
cumstances the  duty  of  the  physician  to  be  prepared  to  expound 
the  most  rational  arrangement  in  candid  and  suitable  words, 
and  even  to  dwell  on  the  necessity  of  properly  separating  the 
thighs  and  raising  the  sacrum.  Doubtless  a  great  deal  of  tact 
is  in  such  cases  required,  especially  in  the  presence  of  female 
modesty,  the  more  so  as  the  number  of  virgins  contracting 
matrimony  is  far  greater  in  proportion  than  that  of  chaste 
young  men,  not  only  among  the  upper  classes  but  also  among 
the  lower.  I  decidedly  believe  this  to  be  the  case  although  the 
wife  is  generally  the  better  informed  partner  in  matters  per- 


lDas  Weib  in  der  Natur-  und  Volkerkunde.     4th  edit.     Leipsic  1895. 


SEXUAL  HYGIENE  IN  MARRIED  LIFE      213 

taining  to  the  married  state  and  in  spite  of  occasional  astonish- 
ing confessions.  I  think  it  necessary  to  emphasize  the  point, 
as  there  are  many  others  of  a  different  opinion,  and  because  of 
the  incredible  statement  publicly  made  a  few  years  ago  by  a 
Berlin  theologian  which  drew  upon  him  a  well-merited 
rebuke. 

In  addition  to  the  natural  position  there  are  quite  a  number 
of  others  which  have  to  a  great  extent  been  adopted  by  both 
uncivilised  and  civilised  nations  but  which  we  cannot  regard  as 
normal.  This  applies  to  the  lateral  position,  the  dorsal  position 
of  the  man,  the  coitus  cum  uxore  inverse,  which  may  go  so  far 
as  to  imitate  the  process  in  animals,  that  is  copulation  while 
standing  or  sitting.  To  be  quite  frank,  I  can  hardly  think  of 
any  combination  which  does  not  figure  among  my  case-notes  as 
having  been  practised  by  my  patients.  It  is  in  such  cases  difficult 
to  draw  the  line  between  harmless  and  transient  indiscretions 
of  newly-married  people  and  the  subtle  contrivances  of  the 
sensualist.  While  it  is  of  course  the  bounden  duty  of  the  physi- 
cian to  condemn  the  latter  emphatically  not  only  on  moral 
grounds  but  also  on  account  of  the  mechanical  injuries  which 
they  are  apt  to  cause  and  of  which  we  shall  speak  again  later  on, 
there  are  occasionally  circumstances  which  render  a  departure 
from  the  normal  procedure  permissible  and  even  medically  advis- 
able. I  am  thinking  f.  i.  of  the  case  where  it  is  necessary  to  pro- 
tect a  delicate  and  sensitive  wife  from  the  ponderous  weight  of  a 
corpulent  husband.1  I  shall  return  to  this  point  when  discussing 
the  question  of  intercourse  during  pregnancy.  But  there 
may  also  be  a  pathological  sensitiveness  present  in  the  wife 
consequent  on  morbid  processes  in  the  pelvic  or  abdominal 
organs  which  makes  it  imperative  to  prescribe  a  method  of 
connexion  that  would  entail  no  pressure — provided,  of  course 
that  it  is  not  necessary  to  forbid  intercourse  altogether.  In  this 
connection  I  must  also  mention  briefly  the  attitude  of  the  physi- 
cian with  regard  to  the  reflux  of  the  semen  from  the  vagina 


*It  is  evident  that  when  both  husband  and  wife  have  large  abdomens, 
there  are  mechanical  obstacles  against  the  normal  performance  of  the  act, 
and  abnormal  positions  such  as  coitus  a  posteriori  and  others  are  necessarily 
resorted  to.  As  a  rule  however,  the  doctor  is  not  consulted  in  such  cases. 


2i4  HEALTH,  DISEASE,  MARRIAGE 

after  intercourse,  as  a  cause  of  absence  of  conception,  a  condi- 
tion described  by  P.  Muller,1  Hegar,  Kaltenbach  and  other 
gynaecologists.  Apart  from  operative  measures  there  arise  as 
suitable  precautions,  the  dorso-coccygeal  position  of  the  wife 
so  as  to  tilt  the  vagina  backwards,  the  raising  upwards  of  the 
abdominal  walls  in  order  to  aspirate  the  semen,  the  retaining 
of  the  penis  in  the  vagina  for  some  time  until  the  relaxation 
of  the  excited  pelvic  musculature,  the  throwing  of  one  thigh 
over  the  other  after  the  removal  of  the  penis,  the  substitution 
for  the  latter  procedure  of  closing  the  vagina  with  the  fingers 
— not  a  very  agreeable  operation,  etc.  Finally  we  are  compelled 
for  practical  reasons  to  acquiesce  in  the  assumption  of  abnormal 
positions  during  the  act  in  the  not  very  infrequent  abortive 
forms  of  relative  impotency  when  they  render  possible  the  per- 
formance of  marital  intercourse.  The  provisions  indicated  for 
the  exercise  of  sexual  connexion  on  the  part  of  individuals 
affected  with  severer  forms  of  impotency  or  perverse  sexual 
sensations  do  not  belong  to  this  chapter.  It  is  sufficient  here 
on  the  one  hand  to  warn  medical  men  against  placing  too  much 
reliance  on  the  assurance  of  their  patients  that  they  will  undoubt- 
edly benefit  by  giving  way  to  their  voluptuous  and  cynical  phan- 
tasy, and  on  the  other  to  impress  upon  them  the  necessity  of 
retaining  their  sound  judgment  with  respect  to  the  unfounded 
fear  that  serious  diseases  are  apt  to  result  from  the  exercise  of 
the  sexual  act  in  abnormal  positions.  I  do  not  forget  that  many 
medical  men  entertain  the  belief  that  severe  diseases  of  the 
spinal  cord  are  particularly  likely  to  be  caused  by  the  perform- 
ance of  sexual  connection  in  the  standing  position. 

Avoidance  of  force. — It  is  also  necessary  that  the 
sexual  act  shall  take  place  without  the  application  of  force. 
This  injunction  is  very  much  offended  against  especially  by 
brutal  husbands  and  also  by  such  men  whose  rough  nature  does 
not  enable  them  to  appreciate  the  greater  sensitiveness  and  finer 
structure  of  the  female  organism.  What  disastrous  effects  the 
membrum  virile  in  its'erected  state  is  capable  of,  if  used  impetu- 
ously, we  can  see  from  the  no  longer  sparse  authentic  reports 


'Die  Unfruchtbarkeit   der  Ehe.     Stuttgart,    1885. 


SEXUAL  HYGIENE  IN  MARRIED  LIFE      215 

quoted  chiefly  in  the  Manuals  on  Medical  Jurisprudence  and 
known  hardly  well  enough  by  the  medical  profession.  In  more 
than  a  dozen  cases  death  through  haemorrhage  was  caused  by 
severe  injury  to  different  parts  of  the  vagina  and  to  the  clitoris; 
in  the  often  quoted  case  of  Albert,  a  sixteen-year-old  Arab  had 
in  natural  intercourse  among  other  injuries  lacerated  the  vagina 
of  his  very  young  and  not  yet  marriageable  wife  so  completely 
that  it  communicated  with  the  abdominal  cavity.  A  few  years 
ago  a  pregnant  working- woman  aged  26  was  brought  dead  to 
the  hospital  with  which  I  am  connected.  She  had  suddenly  col- 
lapsed bleeding  after  intercourse  in  the  standing  position  with 
the  young  man  to  whom  she  was  engaged  to  be  married  and 
who  was  of  the  same  age.  They  were  both  drunk.  The  autopsy 
(v.  Hansemann]  revealed  a  laceration  of  the  urinary  meatus 
and  of  one  of  the  corpora  cavernosa  of  the  clitoris.  Wichmann 
who  reported  the  case  rightly  concluded  that  the  membrum 
must  have  taken  a  wrong  course  and  overcome  the  resistance 
above  the  introitus  by  the  creation  of  a  false  passage. 

While  injury  to  the  male  genital  organs  in  consequence  of 
intercourse  is  exceedingly  rare,  such  sad  accidents  as  those 
described  above  are  fortunately  also  exceptional  and  to  a  great 
extent  dependent  upon  concurrent  special  circumstances,  f.  i. 
extreme  youth  or  old  age,  pregnancy,  child-bed,  pathological 
conditions  of  the  genitals,  inappropriate  position  during  inter- 
course, excessive  size  of  the  penis,  intoxication,  etc.  But  even 
the  so-called  normal  perforation  of  the  hymen  may  prove 
highly  injurious  inasmuch  as  it  may  cause  profuse  haemorrhage 
or  inflammatory  conditions,  especially  where  a  certain  amount 
of  force  is  needed  to  rupture  a  somewhat  resistant  membrane 
or  where  intercourse  has  been  resumed  before  the  injury  has 
had  time  to  heal  up.1  I  am  perfectly  satisfied  that  the  number 
of  young  married  women  who  have  a  lasting  painful  recollec- 
tion of  their  first  sexual  intercourse  exceeds  by  far  the  number 
of  those  who  venture  to  consult  a  doctor,  whereas  it  but  rarely 


JIn  some  countries,  f.  i.  China,  India,  South  America,  the  hymen  is 
ruptured  by  the  mothers  or  nurses  of  the  children  at  a  very  early  age,  not 
so  much  for  the  sake  of  cleanliness  as  for  the  purpose  of  preparing  them 
for  the  sexual  function. — Ploss-Bartels. 


216  HEALTH,  DISEASE,  MARRIAGE 

happens  that  even  very  sensitive  husbands  suffer  more  than 
temporary  inconvenience  from  slight  superficial  abrasions  on 
the  penis  as  a  consequence  of  their  exertions  in  the  first  days 
of  their  married  life.  I  should  consider  in  such  cases  a  careful 
digital  rupture  of  the  hymen  the  lesser  of  two  evils.  It  is  true 
that  only  a  husband  who  is  himself  a  medical  man  would  adopt 
this  procedure,  otherwise  it  will  hardly  be  possible  to  do  any- 
thing else  but  perform  an  incision  as  the  quickest  and  the 
easiest  method.  Further  measures  as  well  as  the  treatment 
necessary  in  cases  of  vaginismus  which  by  the  bye  must  not  be 
confused  with  the  vaginal  hyperaesthesia  (Olshausen)  so  fre- 
quently seen  in  young  married  women,  will  be  found  in  the  chap- 
ters on  nervous  diseases  and  on  diseases  of  women.  But  even 
under  normal  conditions,  where  both  husband  and  wife  are  in 
perfect  health,  it  is  incumbent  on  the  gentle-mannered  husband, 
as  Ribbing  says,  to  pay  every  consideration  to  the  tender  feelings 
of  his  wife;  he  must  endeavour  to  use  that  discretion  for  which 
Shakespeare's  Imogen  begs  so  diffidently  from  her  husband 
Posthumus.  Very  true  are  the  remarks  with  regard  to 
sexual  trauma  in  the  work  of  Breuer  and  Freud  on  hysteria. 
The  nuptial  injury  to  the  newly  married  woman  may  be  the 
result  of  mental  anxiety  mixed  with  a  fear  of  something 
unknown,  some  foreboding  of  evil.  As  experience  has  fre- 
quently taught  me  even  a  well-beloved  husband  is  capable  of 
inflicting  deep  and  lasting  wounds  to  the  feelings  of  his  young 
wife,  if  he  does  not  know  how  to  restrain  himself  in  the  first 
night  after  the  marriage. 

Time  of  intercourse. — As  regards  the  time  when  sex- 
ual intercourse  is  best  exercised  it  would  appear  that  the  hour 
chosen  almost  instinctively  by  the  majority  of  people,  namely 
the  evening  or  the  time  of  going  to  bed,  is  hygienically  correct, 
if  only  on  account  of  the  necessary  undressing  and  of  the  fatigue 
succeeding  the  act.  That  the  latter  is  as  a  rule  productive  in  the 
man  of  higher — and  even  forceful — degrees  of  somnolence  than 
in  the  woman  may  be  regarded  as  an  established  fact.1  This 


'Translator's  note.     On  this  point  I  am  rather  inclined  to  disagree  with 
the  author. 


SEXUAL  HYGIENE  IN  MARRIED  LIFE      217 

agrees  moreover  with  the  greater  amount  of  activity  on  the 
part  of  the  male  partner  during  the  act,  and  with  the  more 
intense  pleasurable  excitement  which  he  experiences.1  Though 
the  degree  of  orgasm1  is  different  in  different  individuals  and 
dependent  upon  disposition  and  temperament — there  are 
numerous  possible  intermediate  stages  between  a  pleasurable 
feeling  of  contentment  and  frantic  voluptuousness — it  is  very 
seldom  indeed  that  the  sudden  engorgement  and  the  still  more 
rapid  relaxation  after  ejaculation  are  absent  in  any  marked 
degree.2  This  relaxing  effect  possesses  under  physiological 
conditions  a  feeling  of  fitness  but  is  decidedly  antagonistic  to 
the  desire  for  work.  I  must  insist  upon  this  opinion  which  is 
contrary  to  recent  utterances  on  the  subject.  Nevertheless 
there  are  occasionally  married  couples  who  choose  the  morning 
time,  and  others  who  prefer  the  after-dinner  hour,  or  the  time 
after  their  principal  meal.  In  the  one  case  it  is  probably  the 
renewed  vigour  after  a  long  sleep,  in  the  other  an  increased 
desire  through  food  and  drink  and  especially  alcoholic  liquors 


According  to  Guttzeit  as  many  as  4  out  of  every  10  women  do  not 
experience  any  sensation  in  sexual  intercourse.  O.  Adler  who  has  treated 
of  the  Anaesthesia  sexualis  feminarum  or  "Dyspareunia"  (Kisch)  in  a  special 
work  which  has  just  appeared  (Berlin  1904)  is  inclined  to  agree  with  this 
opinion.  Though  I  am  prepared  to  accept  the  statement  that  total  and 
partial  anaesthesia  is  exceedingly  frequent  in  women,  as  it  is  so  very  difficult 
to  obtain  reliable  statistics  on  the  point,  I  cannot,  judging  from  my  exper- 
ience, allow  the  above  figure  (40%  !)  to  pass  unless  we  include  the  lightest 
forms  of  female  anaphrodisia.  Whether  it  is  true  that  under  some  circum- 
stances coitus  a  posteriori  is  therapeutically  indicated  in  order  to  excite  suffi- 
ciently certain  parts,  I  am  not  in  a  position  to  say.  It  is  however  strange 
that  a  very  recent  pamphlet  on  the  sexual  sensation  in  woman  and  man 
from  the  pen  of  a  lady,  J.  Elberskirchen,  insists  on  the  equality  of  the  female 
desire  and  demands  free  satisfaction  of  the  same  within  physiological  limits. 
What  has  so  far  been  established  by  statistics  does  not  seem  enough  to  justify 
the  suppression  of  the  wish  for  further  enlightenment  on  the  subject. 

'According  to  von  Krafft-Ebing  the  orgasm  in  woman  both  appears  and 
disappears  more  slowly  than  in  man.  Adler  gives  two  different  charts,  one 
with  an  acute  angle,  the  other  with  an  obtuse,  which  he  associates  with 
dyspareunia.  Where  the  husband  does  not  accommodate  himself  accordingly 
out  of  consideration  to  the  wife  the  latter  does  not  miss  anything  or  else 
completes  the  act  manually.  I  know  a  large  number  of  similar  cases,  but 
deviations  from  these  charts  and  from  their  conclusions  are  probably  more 
frequent. 


218  HEALTH,  DISEASE,  MARRIAGE 

which  is  the  determining  factor.  As  a  matter  of  fact  I  have 
occasionally  in  cases  where  proper  erection  was  not  obtainable 
in  the  evening,  like  Rohleder,1  recommended  with  success  a 
change  to  other  times  of  the  day.  As  a  rule  however  the 
physician  should  in  my  opinion  oppose  such  practices  as  they 
are  likely  to  grow  into  a  habit,  especially  where  heavy  meals 
come  into  consideration.  The  reason  is  to  be  found  in  the 
above  remarks  to  which  we  ought  to  add  the  danger  of  serious 
accidents  in  the  case  of  elderly  people,  particularly  where  there 
is  an  inclination  to  arteriosclerosis  (apoplexy).  There  is  also 
some  risk  of  gastric  and  intestinal  troubles  in  the  exercise  of  the 
sexual  act  immediately  after  a  meal  (Fere),  while  Cursch- 
mann2  and  LowenfeltP  are  distinctly  opposed  to  all  exertion 
after  the  act  as  being  highly  weakening.  Finally,  sexual  inter- 
course during  intoxication,  to  the  dangers  of  which  with  respect 
to  injuries  I  have  already  referred,  is  according  to  Donner,  on 
account  of  the  prolongation  of  the  act,  equal  in  its  effect  to  that 
of  excess.  Sexual  intercourse  should  never  take  place  in  tight- 
fitting  clothes. 

For  the  rest  I  am  not  in  a  position  to  lay  down  any  definite 
practical  rules  with  regard  to  the  choice  of  time,  particularly 
in  respect  of  a  sexual  periodicity  such  as  Havelock  Ellis*  is 
inclined  to  adopt  from  comparison  with  the  habits  of  male  and 
female  masturbators.  Though  certain  individuals  do  occasion- 
ally exhibit  within  physiological  limits  a  certain  regularity  in 
the  fluctuation  of  their  sexual  desire,  it  does  not  seem  proper 
to  speak  of  weekly  cycles  and  monthly  crises.  For  it  is  just  this 
characteristic  differential  quality  which  distinguishes  man  from 
animals.  Whereas  nature  has  in  the  case  of  many  of  the  latter 
ordained  that  the  powerful  sexual  desire  which  is  necessary  for 
the  continuation  of  the  species  shall  recur  periodically  (rut), 
she  has  been  so  generous  to  the  former  as  to  provide  him  with 
a  continuous  sexual  ability  for  the  whole  of  his  sexual  life. 


'Ueber  Sexualtrieb  und  Sexualleben  des  Menschen.  2d  edit.  Berlin 
1902. 

*Die  functionellen  Storungen  der  Mannlichen  Genitalien.  v.  Ziemssen's 
Handbuch  d.  spez.  Pathol.  u.  Ther.  IX.  2.  1878. 

'Sexualleben  und  Nierenleiden.   3d  edit.    Wiesbaden  1903. 

'Geschlechtstrieb  und  Schamgefiihl.    Kbtscher.    2d  edit.    Leipsic,   1901. 


SEXIML  HYGIENE  IN  MARRIED  LIFE      219 

This  is  also  shown  by  the  superior  sexual  activity  of  the  man 
over  that  of  the  woman,  and  it  is  only  the  masturbator  with 
his  practically  unlimited  opportunities  to  satisfy  his  craving 
who  is  better  off  with  regard  to  a  fixed  time.  But  just  because 
it  is  so,  just  because  the  husband  may  choose  the  time  and  hour 
at  his  pleasure  and  just  because  he  is  the  one  that  receives  as  a 
rule  more  enjoyment  from  the  sexual  intercourse,  but  also 
because  the  connubial  state  interests  two  individuals,  I  am 
inclined  to  agree  with  Ribbing  that  it  is  not  right  for  one  of 
these  individuals  to  decide  alone  the  common  affairs  of  the 
partnership.  The  considerate  husband  is  received  quite  differ- 
ently in  the  nuptial  bed  than  the  brutal  egotist.  On  the  other 
hand  it  is  to  be  remembered  that  refusal  to  fulfil  one's  conjugal 
obligations  constitutes  in  some  countries  one  of  the  grounds  for 
divorce.  The  conduct  of  the  husband  during  menstruation  and 
pregnancy  will  be  discussed  more  fully  later  on. 

Frequency  of  sexual  intercourse. —  More  diffi- 
cult to  decide  than  the  points  considered  so  far  is  the  question 
as  to  how  often  the  sexual  act  should  be  exercised.  In  this 
connection  we  have  for  guidance  a  number  of  ancient  legisla- 
tive enactments.  Zoroaster,  Solon  and  Mohammed  prescribe 
under  normal  circumstances  three  to  four  connubial  embrace- 
ments  in  a  month.  The  Talmud  differentiates  in  its  injunctions 
according  to  the  social  position  and  vocation  of  the  individual; 
the  well-to-do  and  strong  young  man  who  is  not  engaged  in  any 
laborious  work  is  required  to  fulfil  his  marital  duty  every  day, 
whereas  artisans,  workmen  and  scholars  being  busy  men  and 
having  exacting  work  to  perform,  should  not  be  called  upon 
more  than  once  or  twice  a  week  and  ought  even  to  be  permitted 
occasional  long  pauses,  lasting  one  or  more  months.  Luther's 
dictum  "Die  Woche  zwier"  (twice  a  week)  is  well-known  both 
to  doctors  and  laymen.  In  modern  times  such  numerical  pre- 
scriptions have  to  a  great  extent  fallen  into  disuse,  probably 
because  it  has  been  recognised  more  and  more  that  even  within 
physiological  limits  the  sexual  ability  of  individuals  differs  very 
much,  and  that  it  is  exceedingly  difficult  to  draw  the  line  between 
normality  and  abuse.  Though  this  law  has  been  advocated 
most  convincingly  by  such  experts  as  Curschmann,  Erb,  v. 


220  HEALTH,  DISEASE,  MARRIAGE 

Gyurgovechky*  Eulenburg,2  Lowenfeld  and  others,  it  has  been 
my  endeavour,  having  come  across  all  kinds  of  possible  inter- 
mediate degrees  between  indefatigable  insatiety3  and  extreme 
moderateness,  to  point  out  that  even  in  the  same  individual 
the  normal  sexual  potency  fluctuates  within  wide  boundaries. 
Nevertheless  I  am  of  the  opinion  that  the  extraordinary  devia- 
tions from  the  average  form  the  exception — even  Mante- 
gazza  speaks  of  his  "grandi  amatori"  as  rarities — and  that  a 
numerical  rule  for  the  average  man  is  not  to  be  regarded  quite 
as  "ridiculous."  Ribbing  says:  "It  would  be  better  for  many  a 
marriage  if  such  a  rule  were  generally  adopted."  To  reject  a 
number  altogether  because  it  does  not  apply  to  everybody  would 
be  regrettable  both  from  the  point  of  view  of  the  doctor  as 
well  as  from  that  of  the  patients  seeking  his  advice.  There  must 
be  some  guiding  general  principle  unless  we  wish  to  leave  the 
matter  entirely  to  the  decision  of  each  individual  and  to  let 
every  one  find  out  for  himself  what  he  should  do,  on  the  basis 
of  "  experientia  docet."  -  Although  the  errors  of  youthful 


Pathologic  und  Therapie  der  mannlichen  Impotenz.  2d  edit.  Vienna 
and  Leipsic  1897. 

"Sexuale  Neuropathic,  Genitale  Neurosen  und  Neuropsychosen  der  Man- 
ner und  Frauen.  Leipsic  1895.  .. 

'We  have  an  example  of  a  real  Don  Juaii  in  Nero  £and  hjs  counter-part 
Messalina),  who,  like  the  legendary  Tannhauser,  can  hardly  be  regarded 
as  a  non-existent  phantom.  There  have  been  many  who  have  been  capable 
with  impunity  of  ten  times  the  amount  allowed  by  Luther  (Erb),  Trousseau 
mentions  tabetics  who  could  perform  the  act  eight  to  ten  times  in  one  day 
or  night.  Lowenfeld  has  reported  of  even  more  in  healthy  individuals.  A 
gentleman  54  years  of  age,  has  to  my  knowledge  had  sexual  intercourse  with 
his  wife  on  an  average  twice  daily  for  many  years  though  an  examination 
revealed  diabetes.  A  merchant  of  the  same  age  had  (adulterous)  connection 
no  less  than  fifteen  times  in  three  consecutive  days  without  any  marked 
inconvenience.  Finally  a  young  Russian  confessed  to  me  that  in  the  first 
years  of  his  married  life  he  had  connection  with  his  wife  every  night  three 
or  four  times,  without  feeling  in  any  way  the  worse.  The  orgies  of  young 
married  couples  on  their  honeymoon  are  sometimes  past  all  description,  and 
yet  they  do  not  necessarily  lead  to  any  ill  results.  The  translator  would 
like  to  add  to  these  experiences  a  case  from  his  own  practice,  and  that  is, 
a  man  about  36  years  old,  married  now  some  10  years,  who  in  spite  of  (or 
perhaps  on  account  of?)  chronic  gonorrhoea  is  able  to  have  frequent  con- 
nection with  his  wife,  often  as  much  as  4  or  5  times  in  one  night.  He  is  not 
by  any  means  a  robust  man,  and  probably  tuberculously  inclined.  Perhaps 
the  last-mentioned  circumstance  is  not  without  its  significance. 


SEXUAL  HYGIENE  IN  MARRIED  LIFE      221 

orgies  and  the  consequences  of  excesses  in  the  happy  early  years 
of  marriage  often  correct  themselves  after  a  time,  there  are 
still  a  considerable  number  of  cases  left  in  which  the  observing 
eye  of  the  physician  may  detect  impending  or  accomplished 
trouble  and  advise  accordingly.  I  have  too  often  had  occasion 
to  explain  to  guileless  young  couples  the  connection  between 
cause  and  effect  to  allow  myself  to  rest  satisfied  with  a  policy 
of  "laissez  faire,"  and  to  place  my  reliance  on  individual  dis- 
cretion and  self-control.  The  choice  between  a  numerical  rule 
and  guidance  by  one's  subjective  feeling  post  coitum  is  often 
anticipated  by  serious  mischief,  and  for  this  reason  I  have  for 
many  years  unhesitatingly  recommended  under  anything  like 
''normal"  circumstances — and  it  is  the  duty  of  the  medical  man 
to  find  these  out — 50  to  100  single  acts  in  the  course  of  a  year 
as  a  hygienic  precaution.  This  limitation  which  takes  into 
account  the  menstruating  periods — but  not  of  course,  pregnancy, 
long  absence  of  either  husband  or  wife,  or  more  or  less  chronic 
diseases,  etc. — leaves  sufficient  room  for  the  fluctuations  due  to 
various  external  causes  as  well  as  to  different  physical  and 
psychical  conditions;  it  is  also,  apart  from  the  older  regula- 
,  tions  discussed  above,  in  fairly  complete  accord  with  the  rule 
laid  down  by  Ribbing  (under  perfectly  normal  circumstances, 
and  between  the  natural  interruptions,  about  3  or  4  times  a 
week)  ;  and  it  is  not  grossly  contradictory  to  the  expert  Acton's 
suggestion  of  a  weekly  turn  in  the  case  of  jaded  town-dwellers. 
It  Js  finally  in  agreement  with  one's  notion  of  true  moderateness 
and  rather  more  reasonable  than  the  over-carefulness  of  the 
philistine.  The  sexual  ability  as  the  manifestation  of  an 
"appetitus  coeundi"  has  not  unaptly  been  compared  to  the 
gastric  and  intestinal  functions.  We  find  this  comparison 
first  expressed  by  Beard  and  Rockwell*  in  a  due  appreciation 
of  the  relative  ideas.  Undoubtedly  the  man  with  a  robust 
digestive  apparatus  can  afford  to  laugh  at  the  individual  who 
in  spite  of  a  healthy  appetite  is  obliged  to  adhere  to  a  strict 
diet;  but  what  these  authors  have  omitted  to  take  into  con- 
sideration is  that  in  eating  and  drinking  it  is  also  necessary 


'Sexual  Neurasthenia,  its  Hygiene,  Etiology,  Symptomatology  and  Treat- 
ment.   2nd  edition. 


222  HEALTH,  DISEASE,  MARRIAGE 

to  be  careful  and  to  avoid  excesses.  For  this  reason  I  am  in 
the  habit  of  answering  in  the  negative  all  questions  as  to  the 
advisability  of  immediate  repetition  of  marital  intercourse  just 
as  I  am  opposed  to  the  practice  of  double  meals  as  being  a 
non-hygienic  procedure.  But  for  all  that  I  do  not  believe  in 
undue  pedantry.  Occasional  outbursts  of  exuberance  when  in 
full  possession  of  the  vital  powers  are  not  generally  of  any 
consequence  especially  in  the  case  of  young  married  couples 
who  enjoy  life  and  have  no  worries  to  weaken  them.  It  is  of 
course  different  where,  as  it  frequently  happens,  May  has 
wedded  December  and  where  the  old  man  notices  that  his  young 
bride  does  not  want  to  be  "spared."1  The  busy  doctor  often 
hears  complaints  on  this  score  from  the  female  partners  as  well. 
He  will  do  well  in  such  cases  to  recommend  as  a  precaution 
against  premature  senile  impotency  the  regular  performance 
of  the  marital  duty,  even  if  the  desire  is  not  very  strong,  so 
"as  to  keep  in  practice."  I  heard  once  this  opinion  confirmed 
unanimously  by  a  company  of  elderly  brother-practitioners, 
when  I  happened  to  be  a  secret  listener.  Fortunately  there 
are  among  women  plenty  of  frigid  natures. 

Consequences  of  sexual  excess. — The  consider- 
ation of  the  concrete  forms  of  the  injury  to  health  caused  by 
excess  of  connubial  intercourse,  both  absolute  and  relative,  is 
outside  my  present  task  and  I  must  refer  the  reader  to  the 
special  chapters  of  this  work  in  which  experienced  specialists, 
neurologists,  and  gynaecologists  treat  of  the  different  subjects 
in  this  connection.  Personally  I  have  for  many  years  devoted 
considerable  attention  to  the  question  and  will  here  only  sum- 
marise that  in  definition  of  sexual  neurasthenia  I  have,  in 
spite  of  my  unshaken  belief  in  the  predominance  of  a  nervous 
predisposition,  attached  a  very  important  aetiological  part  to 


'In  my  opinion  the  decisive  turn  in  a  man's  life  falls  on  an  average  in  the 
sixth  decade,  or  possibly  in  the  middle  of  the  fifth,  though  it  is  by  no  means 
a  rare  thing  to  come  across  men  of  over  60  who  are  perfectly  potent.  It  would 
not  be  amiss  if  the  legislature  which  recognises  a  minimum  marriageable  age 
would  take  into  consideration  this  aspect  of  the  matter  as  well,  especially 
in  view  of  the  circumstance  that  there  are  always  a  large  number  of  old  men 
on  the  look-out  for  young  wives.  Often  enough  the  health  of  these  people 
suffers  objectively,  a  fact  pointed  out  by  Lowenfeld  and  others. 


SEXUAL  HYGIENE  IN  MARRIED  LIFE      223 

sexual  injuries.  It  is  here  where  sexual  mismanagement  shows 
its  characteristic  results.  The  excessive  natural  coitus  is  in  this 
respect  certainly  far  behind  masturbation  with  its  devastating 
effects — almost  all  authors  agree  upon  this  point — and  the 
experienced  practitioner  will  in  principle  share  the  view  of 
Curschmann  that  marriage  directs  the  unbridled  passions  into 
the  right  channel.  But  serious  consequences  of  extravagant 
nuptial  intercourse  are  by  no  means  unknown,  and  it  is  prin- 
cipally the  husband  who  is  by  nature  more  sensually  and  pas- 
sionately inclined  that  suffers  from  them  to  a  greater  extent 
than  the  wife  whose  nervous  system  is  far  less  affected  by  the 
sexual  act;  even  if  we  ignore  entirely  for  the  moment  impo- 
tency  and  spermatorrhoea.  This  explains  how  it  happens 
sometimes  that  while  the  husband  becomes  after  marriage  more 
and  more  miserable  the  wife  becomes  more  and  more  healthy- 
looking.  (Lowenfeld.)  Even  individuals  formerly  in  the 
best  of  health  may  pay  heavy  tribute  to  the  too  frequent  marital 
intercourse  in  the  shape  of  typical  neurasthenia.  Thus  Bins- 
wanger1  was  able  to  demonstrate  connubial  excess  in  very 
young  or  very  old  married  persons  as  the  only  cause  of  neu- 
rosis ;  and  Eulenburg  has  seen  sexual  neurasthenia  as  an 
immediate  consequence  of  highly  exhausting  venereal  orgies. 
Though  in  the  majority  of  cases  the  ill-effects  disappear  more 
or  less  completely,  there  remain  occasionally,  especially  in 
newly-married  individuals,  most  serious  disturbances  of  a 
permanent  nature  as  a  result  of  sexual  abuse.  I  must  in  this 
respect  agree  with  the  opinion  of  Lowenfeld.2 

Conduct  during  menstruation.— How  should  mar- 
ried people  conduct  themselves  during  menstruation  ?  This 
question  has  received  but  little  consideration  in  scientific  litera- 


JDie  Pathologic  u.  Therapie  d.   Neurasthenic.     Jena  1896. 

*In  a  case  observed  by  Hammond  a  young  man  developed  as  a  penalty 
for  having  executed  the  sexual  act  eleven  times  within  eight  hours — only 
the  first  three  times  with  ejaculation — immediate  and  rapid  epilepsy,  and  per- 
manent impotency.  The  paralysis  of  the  lower  extremities  which  the  writer 
saw  in  a  woman  under  similar  circumstances  was  probably  hysterical.  Into 
the  debate  whether  excessive  intercourse  is  capable  of  producing  in  both  sexes 
more  or  less  permanent  inflammatory  conditions  or  in  other  words  organic 
troubles  I  cannot  enter  here. 


224  HEALTH,  DISEASE,  MARRIAGE 

ture.  Perhaps  because  it  was  thought  self-evident  that  no  man 
would  come  near  his  wife  while  she  is  menstruating.  The 
Mosaic  law  goes  even  so  far  as  to  speak  of  capital  punishment 
in  connection  with  the  matter  and  though  it  may  not  be  proved 
that  such  punishment  was  ever  carried  out  it  is  plain  as  we 
read  in  Ploss  and  Bartels  work  that  the  menstruating  woman 
has  always  been  and  still  is  to  some  extent  considered  as  unclean. 
According  to  the  law-book  of  the  Mohammedans  the  husband 
who  has  connection  with  his  wife  while  she  is  menstruating 
loses  the  faculty  of  mental  repose.  The  menstruating  woman 
occasions  also  other  troubles,  endangers  vegetation,  etc.  Hence 
the  regulation  among  several  nations  commanding  women  to 
undergo  a  definite  purifying  process  after  the  cessation  of  men- 
struation. 

But  there  are  in  my  opinion  besides  the  belief  in  the  inju- 
riousness  of  sexual  intercourse  during  menstruation,  which 
acts  in  many  parts  as  the  only  deterrent,  other  reasons  as  well 
why  cohabitation  should  be  suspended  during  the  periods. 
There  is,  primarily,  the  hurt  to  the  aesthetic  feelings  in  the 
presence  of  disagreeable  often  malodorous  coagula  adherent  to 
the  genitals.  More  important  still  is  the  necessity  of  sparing 
the  female  organs  at  a  time  when  they  are  as  a  rule  subject  to 
increased  sensitiveness  and  diminished  resistibility.  How  little 
consideration  many  individuals  show  in  this  respect  I  can  tell 
from  a  good  many  confessions  made  to  me  by  sensual  men  who 
have  during  menstruation  sexually  treated  their  wives  not  much 
differently  than  at  other  times.  I  have  no  hesitation  from  the 
hygienic  point  of  view  in  declaring  intercourse  during  men- 
struation as  generally  unpermissible  even  if  the  continence 
necessitated  by  this  injunction  should  extend  over  periods  as 
long  as  a  fortnight  or  in  other  words  over  the  half  of  the 
sexual  interval.1  It  must  not  be  inferred  however  that  I 
regard  it  as  a  calamity  if,  as  it  often  occurs,  intercourse  happens 


'Without  regard  to  the  still  debated  point  whether  the  sexual  instinct 
of  healthy  women  is  more  pronounced  during  or  shortly  before  and  after 
menstruation  or  if  modesty  prevents  them  from  owning  to  it.  (Ellis,  v.  Krafft- 
Ebing.)  That  menstruation  in  women  must  not  be  compared  to  the  rut  of 
animals  has  already  been  mentioned. 


SEXUAL  HYGIENE  IN  MARRIED  LIFE       225 

unknowingly  to  take  place  simultaneously  with  the  commence- 
ment of  a  period  or  if  a  period  which  is  considered  to  be  at  an 
end  is  resuscitated  by  a  sexual  act.  The  less  so  as  the  interest- 
ing controversy  whether  menstrual  blood  can  act  injuriously 
on  the  male  urethra  is  probably  in  spite  of  opinions  to  the  con- 
trary decided  in  the  negative.  My  own  experience  that  what 
we  meet  with  in  such  cases  are  no  more  than  harmless  and 
insignificant  complaints  arising  from  a  non-virulent  urethritis, 
is  in  accord  with  the  opinions  of  various  gynaecologists  and 
urologists.  Thus  v.  Zeissl,  Sims  and  Finger1  emphasise  par- 
ticularly the  disinclination  of  mucous  pseudo-gonorrhoeas 
resulting  from  intercourse  with  menstruating  or  leucorrhoic 
women  to  assume  any  chronic  forms  or  further  development. 
Conduct  during  pregnancy. — The  sexual  hygiene  of 
the  married  state  during  pregnancy  which  if  noticed  at  all 
receives  but  scanty  consideration  in  text-books  and  manuals, 
is  not  less  important  than  that  during  menstruation.  On  the 
contrary,  it  deserves  even  greater  attention  seeing  that  on 
account  of  the  much  longer  duration  of  the  period  in  ques- 
tion there  is  a  correspondingly  greater  danger  of  undesirable 
conduct  on  the  part  of  the  husband  arising  from  the  enforced 
continence.  A  new  element  of  risk  is  moreover  introduced 
in  the  shape  of  miscarriage  which  is  a  source  of  peril  to  the 
health  of  the  mother  and  to  the  life  of  the  foetus  though  there 
is  perhaps  a  certain  exaggeration  in  connection  with  the  subject. 
The  want  of  unanimity  in  the  opinions  on  the  matter  is  apparent 
on  the  one  hand  from  Kleinwaechter's  demand  that  intercourse 
shall  be  restricted  and  in  the  second  half  of  the  pregnancy 


^Finger  demonstrates  in  his  well-known  work  "Blenorrhce  der  Sexual- 
Organe"  (5th  edit.  Leipsic  Vienna  1901)  peculiar  bacilli  enclosed  in  round 
cells  as  the  possible  cause  of  the  mucous  discharge.  Bockhart  and  L.  Casper 
also  believe  in  a  bacterial  origin  ("Bacteriorrhoea").  The  occasional  chro- 
nicity  observed  by  Diday  and  Lyon  is  probably  as  Raciborski  truly 
says  due  also  to  other  causes.  What  I  have  seen  in  connection  with  inter- 
course during  menstruation  and  with  women  suffering  from  non-virulent 
catarrh  have  always  been  acute  processes.  Often  enough  there  is  nothing 
else  noticeable  but  a  few  transparent  filaments  in  the  urine  which  occasions 
very  little  inconvenience,  a  condition  resembling  that  which  is  often  caused 
by  frequent  sexual  intercourse.  Where  there  is  no  gonococcus  there  can  be 
no  danger  in  this  respect. 


226  HEALTH,  DISEASE,  MARRIAGE 

abstained  from  altogether,  and  on  the  other  from  the  sug- 
gestion which  E.  Fraenkel  makes  in  his  recently  published 
book  "Hygiene  des  Weibes"  (The  Hygiene  of  Woman) 
Berlin  1903,  that  there  ought  to  be  no  connection  between 
husband  and  wife  during  the  last  few  weeks  of  pregnancy 
on  account  of  the  danger  of  introducing  into  the  vagina  micro- 
organisms likely  to  lead  to  inflammatory  troubles.  These  are 
enormous  differences  which  it  is  difficult  to  reconcile  and  against 
which  I  am  not  in  a  position  to  advance  a  definite  proposal. 
I  consider  however,  to  be  brief  on  the  point,  that  an  abstinence 
during  the  whole  second  half  of  the  period  of  pregnancy  is 
likely  to  be  to  some  husbands  a  very  serious  matter  and  one 
involving  the  happiness  of  many  a  married  couple.  For  this 
reason  I  have  made  it  a  rule  to  advise  my  patients  under  ordi- 
nary circumstances  to  abstain  from  intercourse  entirely  begin- 
ning with  the  sixth  or  seventh  month.  This  restriction  of 
which  libidinous  husbands  will  often  enough  take  no  notice 
leaves  in  my  opinion  sufficient  room  for  individualistic  dis- 
positions to  assert  themselves  where  particular  conditions  of 
ill-health  do  not  necessitate  a  different  conduct.  With  this 
part  of  the  subject  however  I  am  not  dealing  now  as  it  does 
not  belong  to  the  present  chapter.  A  predisposition  to  miscar- 
riage may  at  times  form  an  absolute  prohibition.  That  inter- 
course during  pregnancy  is,  as  regards  man,  not  to  be  looked 
upon  under  all  circumstances  as  an  unnatural  proceeding  is 
admitted  even  by  Ribbing  who  is  otherwise  so  very  cautious. 
But  he  advises  very  great  care  and  especially  so  in  the  case 
of  first  pregnancies.  This  means  in  my  opinion  not  only  a 
restricted  number  of  single  acts  but  also  a  more  gentle  and 
careful  manner  of  performing  each  one.  Referring  to  what 
has  been  said  above  I  should  like  to  mention  here  that  in 
advanced  pregnancy  people  often  adopt  for  intercourse  the 
lateral  position  without  taking  first  the  doctor's  advice.1  In  con- 


'Occasionally  it  is  done  with  the  wife  sitting  somewhat  elevated.  The 
practitioner  need  not  regard  this  position  which  approximates  connection 
in  the  standing  position  as  impermissible,  considering  the  exceptional  cir- 
cumstances, provided  care  is  taken  not  to  subject  the  pregnant  abdomen  to 
pressure. 


SEXUAL  HYGIENE  IN  MARRIED  LIFE      227 

trast  to  this  cautiousness  and  consideration  for  the  wife  I  wish  to 
call  attention  to  the  brutal  habit  of  some  husbands — "unfor- 
tunately very  frequent"  (He gar1) — who  make  voluptuous 
use  of  their  pregnant  wives  in  the  usual  way  up  to  shortly  before 
their  confinement.  How  different  were  the  customs  of  various 
ancient  nations !  The  Persians  f .  i.  prohibited  sexual  intercourse 
with  the  pregnant  wife  under  penalty  of  corporal  punishment. 
The  Talmud  also  declares  copulation  in  the  first  3  months  after 
conception  as  deleterious  both  to  the  pregnant  woman  and  the 
foetus,  and  later  intercourse  is  characterised  as  an  action  which 
is  destructive  of  human  life.  In  China  total  abstinence  is  one 
of  the  first  medical  laws  (Ploss  and  B artels) .  In  many  places 
pregnancy  is  like  menstruation  looked  upon  as  a  state  of 
uncleanness  requiring  separate  accommodation.  Finally  it  is 
worth  mentioning  that  to  some  sensitive  and  "aesthetic"  natures 
(as  I  can  testify  from  personal  experience)  the  roomy  secreting 
vagina  and  the  oedematous  vulva  are  in  themselves  sufficient 
to  deter  them  from  cohabiting  with  their  pregnant  wives.  As 
regards  the  acquisition  of  urethritis  in  consequence  of  inter- 
course with  the  pregnant  wife  (v.  Zeissl  and  others)  the  same 
may  be  said  as  with  regard  to  connection  during  menstrua- 
tion. 

If  I  do  not  see  any  objection  to  allowing  my  patients 
under  ordinary  circumstances  to  cohabit  with  the  pregnant 
wife  beyond  the  middle  of  the  period  of  pregnancy  it  is  as 
I  have  already  indicated  principally  on  account  of  the  attitude 
some  husbands  would  adopt  if  compelled  to  abstain  for  too 
long  from  sexual  intercourse.  The  "concession"  is  the  more 
reasonable  as  in  accordance  with  the  advice  I  am  in  the  habit 
of  giving  with  reference  to  the  abstention  during  the  period 
of  involution  the  time  of  continence  extends  over  several 
months.  So  as  to  make  it  clear  what  such  a  long  continued 
absence  signifies  and  in  order  that  it  may  be  appreciated  fully 
I  consider  it  advisable  to  give  here  a  brief  summary  of  the 
much  discussed  question  of  the  "consequences  of  sexual  con- 
tinence" and  of  the  many  contradictory  opinions  concerning  the 


*Der  Geschlechtstrieb.     Stuttgart  1894. 


228  HEALTH,  DISEASE,  MARRIAGE 

same,  while  referring  for  further  details  to  my  several  other 
contributions  on  the  subject. 

Sexual  abstention. —  I  have  now  for  a  number  of 
years  on  the  strength  of  personal  observations,  which  are  no 
longer  limited  in  number,  and  at  the  risk  of  being  regarded 
as  a  sermoniser  opposed  most  strenuously  the  belief  in  the 
injuriousness  of  sexual  continence  which  was  inaugurated 
chiefly  by  the  teaching  of  Lallemand  and  is  unfortunately  still 
very  prevalent  among  doctors  and  the  public.  Many  eminent 
men  are  at  the  present  time  in  agreement  with  me  and  I  have 
only  to  mention  such  names  as  Ribbing,  Hegar,  Eulenburg, 
Loewenfeld  and  Rohleder — all  these  authorities  have  dealt 
with  this  interesting  subject  most  minutely1 — to  demonstrate 
the  progress  of  the  principle  that  the  control  of  the  sexual 
desire  within  wide  limits  is  not  only  permissible  but  even  neces- 
sary from  the  hygienic  standpoint,  in  spite  of  its  being 
admittedly  a  powerful  natural  impulse.  There  are  of  course 
gradations.  One  case  may  require  the  declaration  that  abso- 
lute suppression  of  the  desire  is  a  harmless  measure,  that 
so-called  "diseases  of  abstinence"  are  invented,  though  readily 
believed  and  thoughtlessly  repeated,  stories  (Ribbing,  Eulen- 
burg),  another  the  mere  refusal  to  attribute  to  abstinence  the 
causation  of  more  or  less  serious  disorders.  (Lowenfeld.) 
Personally  I  have  always  listened  skeptically  to  the  tales  of 
my  patients  assigning  all  sorts  of  conditions  such  as  sper- 
matorrhoea, impotence,  neurasthenia,  hysteria,  hypochondriasis, 


'Curschmann,  Forel,  Mendel,  Hoerschelmann,  Blessig,  Masing,  Assmuth, 
Jos.  Mayer,  Herzen,  and  many  others  have  also  worthily  participated  in 
establishing  the  true  hygienic  conclusions  demanded  by  science  and  morality. 
I  may  also  call  here  attention  to  the  recent  order  from  the  Prussian  Minister 
of  Education  to  the  Directors  of  the  Universities  requiring  them  to  warn  the 
students  against  the  dangers  from  venereal  diseases,  considering  that  a  step 
is  thereby  taken  in  the  direction  of  having  the  subject  elucidated  by  experts 
from  the  ethical  point  of  view.  The  instruction  of  young  men  on  the  subject 
of  illegitimate  sexual  intercourse  and  of  its  dangers  is  one  of  the  finest  and 
most  beneficent  objects  of  medical  societies.  In  a  "warning"  issued  by  the 
''German  Society  for  the  Prevention  of  Venereal  Diseases,"  which  has  just 
reached  me  I  read  in  the  first  paragraph  that  sexual  continence  is  in  the 
unanimous  opinion  of  the  medical  profession  generally,  not  injurious  to 
health,  as  it  is  commonly  believed.  This  applies  to  women  also.  B.  Kroenig 
and  others. 


SEXUAL  HYGIENE  IN  MARRIED  LIFE      229 

to  their  sexual  abstention  exclusively,  and  I  can  hardly  remem- 
ber a  single  case  of  a  healthy  individual  in  whom  I  could  dis- 
cover no  other  cause  but  continence  for  conditions  of  ill-health. 
People  do  occasionally  complain  of  discomfort,  of  a  feeling 
of  pressure  or  of  tension  ("spermatic  impulse")  ;  but  these 
inconveniences  are  easily  overcome  and  without  masturbatory 
"correction."  It  must  be  admitted  however  that  there  are 
some  sensually  inclined  and  neuropathically  predisposed  per- 
sons whose  history  does  contain  serious  symptoms  of  sexual 
neurasthenia.1  But  I  think  it  necessary  to  emphasize  that  the 
medical  practitioner  should  not  in  tjhe  presence  of  such  patients 
give  way  to  useless  over-confidence.  Often  enough  it  is  not 
the  continence  which  is  responsible  for  the  illness,  but  mas- 
turbation and  lasciviousness,  though  not  to  such  an  enormous 
extent  as  is  assumed  by  v.  Gyurkovechky.  The  self-regulating 
action  of  normal  emissions — a  subject  which  is  in  my  opinion 
far  too  little  appreciated  in  medical  literature — should  also  be 
borne  in  mind.  Finally,  as  Hegar  says,  the  sexual  desire  in 
present-day  civilised  people,  and  especially  in  women,  is  not 
by  any  means  as  intense  as  it  is  described.  Let  the  reader  note 
the  courageous  struggle  of  this  expert  against  the  pernicious 
doctrine  of  Bebel  that  it  is  dangerous  to  suppress  natural  desires 
and  that  it  is  ordained  that  man  should  not  leave  unused  any 
portion  of  his  body  or  resist  the  gratification  of  natural  require- 


*I  am  obliged  to  recognise  that  the  literature  on  the  subject  does  include 
comparatively  reliable  cases  of  serious  mischief  resulting  from  continence 
(thus  one  fully  reported  by  L.  Casper  of  ejaculatio  ante  portas)  and  that 
highly  authoritative  experts  such  as  v.  Krafft-Ebing  ( Psychopathia  sexualis, 
I2th  edit.  Stuttgart,  1903)  and  v.  Schrenck-Notzing  (Die  Suggestions  thera- 
pie  bei  Krankhaften  Erscheinungen  des  Geschlechtssinnes.  Stuttgart,  1892) 
believe  in  continence  as  a  cause  of  serious  affections  and  even  of  sexual  perver- 
sity. But  I  look  upon  such  cases  as  exceptions  confirming  the  rule.  And  as  to 
"diseases  of  abstinence"  in  women,  even  Krafft-Ebing  considers  them  a  myth. 
As  a  matter  of  fact  those  times  have  long  since  gone  when  "old-maidenhood" 
and  its  peculiar  disturbances  used  to  be  ascribed  to  absence  of  sexual  inter- 
course. Neither  does  it  appear  that  celibates  and  others  who  are  vowed  to 
chastity  are  more  prone  to  neurasthenia.  The  platonic  love  of  adolescence 
may  be  an  "absurdity,"  but,  as  Moll  says  (Die  contrare  Sexualempfindung, 
3d  edit,  Berlin,  1899,  and  Untersuchungen  uber  die  Libido  sexualis,  Berlin, 
1897)  it  is  just  capable  of  conquering  the  "detumescent"  desire  which  is  the 
more  serious  part  of  the  sexual  instinct. 


230  HEALTH,  DISEASE,  MARRIAGE 

ments.  I  cannot  allow  a  comparison  between  the  sexual  desire 
and  the  above  indicated  natural  instincts  of  hunger  and  thirst, 
such  as  is  often  made,  because  food  and  drink  are  vital  neces- 
sities under  any  circumstances.  If  the  parallel  is  to  be  con- 
tinued, there  is  perhaps  more  justification  in  a  reference  to 
drunkenness  and  to  the  struggle  against  the  abuse  of  alcoholic 
liquors. 

On  the  whole,  while  not  exactly  of  the  opinion  that  dis- 
orders due  to  continence  are  entirely  non-existent,  I  have  no 
hesitation  in  agreeing  with  Curschmann  that  genuine  cases  are 
very  rare.  Where  such  are  credibly  alleged,  artificial  irritation 
must  be  supposed  to  play  a  very  important  causative  part  in 
the  majority  of  them.  As  to  the  rest,  "it  is  possible  for  sex- 
ually normal  individuals  whose  resistibility  is  not  diminished 
by  sexual  abuse,  to  endure  permanent  continence  along  with  a 
well-regulated  mode  of  life  without  any  ill-effects  that  are 
worth  mentioning."  (Lowenfeld.) 

This  explains  why,  in  spite  of  occasional  "conflicts  of 
duties"  (Stintzing)  I  have  never  dared  to  recommend  sexual 
intercourse  to  young  men  and  also  why  I  oppose  so  emphati- 
cally the  "connection  cure"  advised  by  other  medical  men, 
advice  which  Rohleder  characterises  as  unscrupulous. 

In  returning  after  this  digression  to  the  subject  of  the 
sexual  hygiene  of  married  persons  during  pregnancy  I  repeat 
that  the  medical  demand  of  abstinence  during  part  of  the 
period  is,  after  what  has  just  been  said,  the  more  reasonable 
as  it  is  only  relative  continence  which  comes  into  considera- 
tion.1 Of  course  we  must  not  forget  that  there  is  an  aggra- 
vating element  in  the  matter,  namely  the  former  regular  per- 
formance of  the  sexual  act  and  the  fact  established  by  expe- 
rience that  sexual  abstinence,  when  compulsory,  is  more  difficult 
of  practical  realisation  than  when  self-imposed  or  voluntary. 
(Rohleder.}  The  above  mentioned  exceptions  are  doubtless 
seen  by  practitioners  to  a  great  extent  after  sudden  dissolutions 
of  marriages  through  the  death  of  husband  or  wife  especially 


*I  wish  to  mention  the  prohibition  of  intercourse  in  various  forms  of 
disordered  potency,  where  prolonged  continence,  extending  over  one  or  more 
months' may  be  remarkably  beneficial. 


SEXUAL  HYGIENE  IN  MARRIED  LIFE      231 

where  there  is  increased  sensual  proclivity  and  associated  with 
it  a  corresponding  sexual  faculty.  On  the  other  hand  there  are 
cases,  as  I  have  often  been  told  and  not  only  by  elderly  couples, 
where  the  conjugal  intercourse  has  for  years  been  restricted  to 
an  unusual  or  even  unseemly  degree.  But  while  there  is  no 
difficulty  about  these  cases,  in  the  others  the  doctor  must  be 
prepared  to  grapple  with  the  hard  task  of  compulsory  con- 
tinence, though  the  latter  is  to  be  a  temporary  one  only. 
Much  may  be  done  in  this  respect  by  the  occupation  of  sepa- 
rate bedrooms,  and  by  increased  mental  and  physical  work  on 
the  part  of  the  husband. 

There  remain  however,  even  if  the  cessation  of  intercourse 
during  pregnancy  is  permitted  to  be  postponed  in  the  sense  of 
my  concession,  not  a  few  cases — and  this  is  the  sore  point  in 
the  whole  question — where  obedience  to  the  doctor  leads  to 
the  adoption  of  devious  ways.  Having  had  occasion  for  many 
years  to  see  what  is  going  on  behind  the  scenes,  I  may  say  that 
of  the  tragedies  not  infrequently  met  with  by  the  practitioner 
as  results  of  an  unrestrained  sexual  nisus  those  oftenest  seen 
are:  secret  adultery  on  the  part  of  the  husband,  masturbation 
and  onanism  performed  by  the  wife  on  the  husband.  I  do 
not  believe  however  that  the  wife,  whose  occasional  inclina- 
tion to  self-help  where  the  husband  denies  her  even  a  reason- 
able amount  of  gratification  I  am  not  prepared  to  deny,  ever 
gives  way  to  masturbation  while  in  a  pregnant  condition. 
She  rather  tends  to  be  grateful  to  the  husband  for  the  for- 
bearance with  which  he  treats  her.  As  to  the  attitude  of  the 
practitioner  with  regard  to  the  question  of  the  gratification  of 
the  husband's  desire  elsewhere,  I  should  not  waste  any  words 
on  the  matter  if  I  had  not  absolute  proofs  of  the  laxity  of 
some  doctors  on  this  score.  I  pity  the  medical  man  who  does 
not  at  all  times  remember  the  great  significance  of  adultery, 
an  offence  neither  required  by  hygiene  nor  sanctioned  by 
society  and  which  is  moreover  in  some  countries  punished 
with  imprisonment.  For  the  rest,  I  consider  the  other  aids 
mentioned  above  also  reprehensible,  but  where  the  dilemma 
is  otherwise  insolvable  they  are  to  be  regarded  as  the  lesser 
of  two  evils,  though  every  effort  must  be  made  to  check  them. 


232  HEALTH,  DISEASE,  MARRIAGE 

It  is  better  to  permit  natural  intercourse  even  in  highly 
advanced  pregnancy,  rather  than  a  deviation  from  the  correct 
attitude, 

Conduct  during  the  period  of  involution.  —  In 

view  of  the  above  remarks  it  is  not  necessary  to  say  very 
much  on  the  sexual  conduct  rendered  hygienically  impera- 
tive by  the  puerperal  condition.  I  do  not  of  course  mean 
here  child-bed  in  the  sense  generally  attributed  to  the  word 
by  the  laity,  that  is  the  average  week  or  two  spent  by  the 
puerperal  woman  in  bed,  though  according  to  Hegar  even 
during  this  short  period  "beastly  transgressions"  do  occur. 
I  mean  a  period  of  involution  extending  approximately  over 
6  weeks,  though  it  certainly  cannot  be  said  that  it  is  abso- 
lutely necessary  in  every  case  to  wait  so  long — that  is,  not 
only  until  there  is  no  sign  left  of  the  lochia  but  until  the  wife 
is  able  to  resume  her  former  mode  of  life — before  intercourse 
may  be  indulged  again.  A  great  deal  depends  on  such  fluctuating 
factors — easily  influenced  by  the  sexual  act — as  lactation,  the 
involution  of  the  genital  organs,  or  the  whole  constitution  of 
the  mother  with  its  eventual  new  duties  necessitating  greater 
cautiousness.  Referring  to  what  I  said  above  on  the  conflict 
of  the  indications  I  do  not  see  anything  objectionable  or 
unhygienic  in  the  doctor's  permission  where  favourable  cir- 
cumstances warrant  it,  to  resume  the  marital  relations  one  or 
more  weeks  earlier. 

There  are  no  special  instructions  necessary  with  regard  to 
conjugal  connection  after  miscarriage,  in  view  of  what  has 
already  been  said.  They  are  easily  inferred  from  the  contents 
of  my  detailed  remarks  on  pregnancy  and  menstruation.  As 
to  more  serious  pathological  conditions,  their  consideration  is 
beyond  the  scope  of  the  present  chapter. 

Preventive  measures. — The  preventive  intercourse 
of  married  couples  in  relation  to  sexual  hygiene,  especially  as 
practised  at  the  present  day,  makes  great  demands  upon  the 
attention  of  the  medical  practitioner.  This  is  not  the  place 
to  prove  its  justification.  Suffice  it  to  say  that  if  we  cast  a 
glance  at  the  married  state  in  its  different  aspects  as  one  of 
the  factors  concerned  in  the  progress  of  a  nation,  if  we  bear 


SEXUAL  HYGIENE  IN  MARRIED  LIFE      233 

in  mind  the  prolonged  period  during  which  woman  retains 
her  conceptive  faculty,  if  we  think  of  the  widely  fluctuating 
uncertainty  as  to  the  consequences  of  normal  cohabitation 
with  respect  to  the  question  of  offspring,  and  if  we  also  take 
into  consideration  what  has  been  minutely  dealt  with  in  these 
pages,  it  is  impossible  to  issue  a  general  prohibition.  This 
does  not  however  imply  complete  indifference  to  the  interests 
of  the  State  which  requires  a  constantly  increasing  population 
on  the  basis  of  legitimate  marriages.  It  does  not  mean  a 
refusal  to  recognise  the  dangers  associated  with  an  exaggerated 
adoption  of  neo-malthusian  principles.  Let  me  at  once  say 
that  so  far  as  I  am  concerned  I  share  at  present  the  views 
expressed  more  than  20  years  ago  by  Hasse  (alias  Mensinga) 
in  his  researches  on  optical  sterility,  and  those  of  the  Munich 
neurologist  Lowenfeld  who  has  recently  thrown  so  much  light 
on  the  subject.  "I  claim  for  every  medical  man  who  is  a  true 
friend  and  counsellor  to  his  patients,  the  inalienable  right  and 
duty  to  utilise  his  own  personal  observation  and  conscientious 
knowledge  with  a  view  to  fixing  the  limit  of  procreation  in 
every  given  case,  and  to  act  accordingly."  "Malthusian 
measures  become  a  necessity  sooner  or  later  to  every  married 
couple  where  the  wife  retains  her  conceptive  faculty  and  the 
husband  does  not  consider  that  he  has  an  incontestable  right 
to  gratify  brutally  his  sensual  desires  without  regard  to  the 
weal  and  woe  of  his  partner  and  of  the  children  already  born." 
More  or  less  similar  opinions  are  held  by  Hegar,  Eulenburg, 
Rohleder,  Stille,  Freud,  Thompson,  Volkmann,  von  Oefele, 
Ferdy  and  many  others.  I  do  not  propose  however  to  go  into 
the  question  whether  the  increase  in  the  artificial  prevention 
of  conception  is  to  be  regarded  as  a  "sign  of  decadence"  or 
rather  as  an  "uplifting  of  the  level  of  our  moral  decay." 

That  the  safest  remedy,  one  which  never  fails,  namely 
absolute  sexual  continence  during  the  whole  of  married  life, 
is  out  of  the  question  I  need  not  dwell  upon.1  We  have  there- 


refusal  on  the  part  of  the  husband,  who  is  the  more  interested 
party,  and  besides  such  untoward  results  as  onanism  and  adultery,  the  un- 
satisfied longing  of  the  wife  for  normal  intercourse  also  deserves  mention- 
ing in  this  connection. 


234  HEALTH,  DISEASE,  MARRIAGE 

fore  to  consider  a  modified  form  of  conjugal  connection. 
I  will  only  mention  in  passing  the  injunction  that  no  inter- 
course should  take  place  for  two  weeks  after  and  3  or  4  days 
before  menstruation.  It  is  not  likely  to  do  more  good  than 
the  instruction  that  the  wife  shall  "remain  cold"  during  the 
act,  and  so  prevent  by  her  passive  attitude  the  reflex  forward 
movements  of  the  seminal  fluid.  The  attempts  to  press  out 
the  semen  by  abdominal  pressure  immediately  after  inter- 
course, as  practised  especially  by  poor  women  in  Italy,  or  to 
"shake  it  off"  by  other  muscular  action  as  it  is  done  f.  i.  in 
Australia  (Ploss  and  B artels}  can  hardly  be  regarded  as 
hygienic  proceedings,  and  far  less  can  we  consider  as  such 
the  custom,  prevalent  particularly  in  France  and  in  the  north- 
ern countries,  of  digitally  compressing  suddenly  the  posterior 
male  urethra  shortly  before  ejaculation.  There  remain  there- 
fore for  serious  discussion  as  hygienic  precautions,  the  inter- 
rupted act,  the  irrigation  of  the  vagina  after  intercourse,  the 
introduction  into  it  before  connection  of  semen-precluding 
apparatuses  (occlusive  pessaries)  or  germ-killing  antiseptics, 
and  finally  the  condom.  The  almost  endless  use  of  all  these 
preventive  agencies  also  by  married  couples,  of  course  by 
mutual  pre-arrangement,  does  no  longer  justify  us  in  passing 
over  the  subject  in  silence. 

Interrupted  intercourse. —  Upon  this  subject  of 
interrupted  coitus  (Congressus  reservatus,  Onanismus  conju- 
galis)1,  that  is  the  withdrawal  of  the  penis  at  the  decisive 
moment,  I  have  already  on  several  other  occasions  given  my 
opinion.  That  the  practice  if  carried  out  for  years  is  capable 
of  producing  a  certain  disturbance  in  the  natural  course  of  the 
mechanism  of  excitation2  and  therefore  an  injurious  counter- 
effect  upon  the  centres  of  innervation  cannot  altogether  be 
denied2.  But  we  must  not  forget  that  ejaculation  does  take 
place  nevertheless  and  there  is  consequently  a  consummation  of 


1Strictly  speaking,  the  vice  attributed  to  Onan,  of  biblical  times,  was  not 
masturbation,  but  interrupted  intercourse  committed  with  his  sister-in-law. 

*Eulenburg  attaches  greater  importance  to  the  "prevention  of  the  evolu- 
tion of  the  automatic-reflex  chains-  of  excitation,"  whereas  v.  Krafft-Ebing 
thinks  more  of  an  imperfect  depletion  of  the  genital  sac. 


SEXUAL  HYGIENE  IN  MARRIED  LIFE      235 

the  orgasm  equal  to  that  of  normal  intercourse,  particularly 
where  there  is  "a  little  assistance."1  And  as  the  last  word  is 
always  spoken  by  clinical  experience,  the  question  can  only  be 
answered  practically  and  empirically  and  I  must  therefore  upon 
the  basis  of  numerous  and  constantly  growing  observations 
repeat  that  I  cannot,  generally  speaking,  impute  from  a  hygienic 
point  of  view  any  serious  harmlessness  to  interrupted  inter- 
course. I  have  seen  cases  in  which  sexual-neurasthenic  symp- 
toms have  become  more  and  more  aggravated  through  a  length- 
ened perseverance  with  the  practice.  But  in  opposition  to  these 
I  have  seen  far  more  numerous  others  in  which  incomplete 
connection  has  been  indulged  in  for  many  years  without  leaving 
behind  any  recognisable  ill-effects,  of  either  a  subjective  or 
objective  nature.  I  also  have  reason  to  suspect  that  interrupted 
intercourse  is  capable  of  causing  considerable  aggravation 
almost  exclusively  in  such  cases  where  there  is  already  an  irritable 
weakness  of  the  nervous  system.  It  is  the  excess  which  is  inju- 
rious and  not  the  "unnaturalness"  of  the  single  act;  and  the 
habitual  practice  has  therefore  the  effect  of  causing  the  glim- 
mering nervous  disease  to  flare  up  the  more  quickly. 

Similar  views  are  held  by  Beard,  v.  Gyurkovechky,  v.  Kraft- 
Ebing,  Oppenheim,  v.  Hosslin,  Rohleder  and  Lowenfeld, 
except  that  they  differ  somewhat  with  regard  to  the  frequency 
and  intensity  of  the  undesirable  consequences.  Thompson 
denies  all  injury  to  the  nervous  system  of  the  man  through  inter- 
rupted intercourse.  I  wish  to  call  special  attention  to  a  valuable 
contribution  of  Lowenfeld  in  which  this  author  gives  a  table  of 
50  cases  (men  and  women)  seen  by  him  in  which  he  very  rarely 
found  the  cause  of  disease  to  lie  exclusively  in  interrupted  coitus. 


lrThis  does  not  of  course  apply  to  the  custom,  frequently  observed  in 
Italy,  and  mentioned  by  Barucco  in  his  "Sexual  Neurasthenia"  (3d  edition, 
German  translation  by  Wichmann,  Berlin,  1899)  of  prolonging  the  sexual 
enjoyment  by  repeated  interruptions  of  the  act  even  with  repeated  erections. 
It  cannot  be  denied  that  this  is  a  pernicious  vice  which  should  on  no  consid- 
eration be  tolerated  by  the  medical  practitioner.  On  the  other  hand,  there  are 
frigid-natured  individuals  who  require  considerable  time  for  the  exercise  of 
the  sexual  act,  without  in  any  way  injuring  their  organism.  A  gentleman 
once  told  me  that  he  frequently  indulges  in  smoking  and  reading  while  thus 
engaged. 


236  HEALTH,  DISEASE,  MARRIAGE 

Von  Krafft-Ebing  has  established  out  of  114  cases  only  one  of 
marked  nervous  debility,  and  even  in  that  one  there  was  a 
neurasthenic  predisposition. 

On  the  other  hand  there  are  opponents  to  this  opinion  whose 
positive  experiences  we  are  bound  to  respect.  Whereas  Freud1 
ascribes  to  interrupted  connection  the  production  of  a  state  of 
anxiety  especially  in  neurasthenic  and  hysterical  individuals  (neu- 
rotic anxiety) ,  Eergeret  and  Peyer  infer  from  their  observations 
an  excessively  frequent  causation  of  sexual  neurasthenic  condi- 
tions, especially  involuntary  spermatorrhoea  and  even  posterior 
urethritis.  Eulenburg  who  has  seen  conjugal  onanism  produce 
serious  forms  of  sexual  nervous  debility  is  not  quite  opposed  to 
the  idea  that  it  may  also  give  rise  to  local  organic  diseases  of  the 
genital  organs  especially  in  the  wife,  agreeing  in  this  respect 
with  Kisch  and  Valenta.  Finally  Hirt,  Barucco,  v.  Tschich, 
Gattel,  and  others  impute  to  the  habit  considerable  importance 
as  a  disease-producing  element. 

In  order  to  find  some  sort  of  compromise  between  the 
diverging  opinions  I  should  feel  inclined  to  believe  that  the  last 
named  authors  have  accidentally  come  across  a  larger  number  of 
unfavourable  cases.  Anyhow  I  am  not  in  favour  of  a  general 
matter-of-course  prohibition  on  the  part  of  the  medical  prac- 
titioner. Each  case  should  be  decided  on  its  merits.  It  is  also 
worth  remembering  that  where,  as  it  frequently  happens,  the 
wife  experiences  no  orgasm  even  with  the  intercourse  fully 
accomplished  she  is  no  worse  off  when  the  act  is  interrupted. 
Considering  how  enormously  frequently  abortive  forms  of  pre- 
cocious ejaculation  occur  among  the  men  of  our  present  day  I 
attach  no  importance  to  it.  Loewenfeld  is  quite  right  when  he 
says  that  most  wives  are  contented  with  a  very  moderate  amount 
of  sexual  enjoyment  in  their  married  state.  That  the  habit  of 
interrupted  intercourse  could  lead  a  wife  to  unfaithfulness  is  not 
impossible  but  it  is  not  likely  to  happen  often. 

The  reliability  of  interrupted  connection  as  a  means  of  pre- 
venting conception  though  by  no  means  insignificant  is  on  the 


'Die  Sexualitat  in  der  Aetiologie  der  Neurosen    (Wiener  klin.   Rund- 
schau, 1898:) 


SEXUAL  HYGIENE  IN  MARRIED  LIFE      237 

other  hand  certainly  not  absolute.  I  have  heard  quite  a  number 
of  confessions  that  owing  to  a  miss  on  the  part  of  the  husband 
the  pre-arranged  plan  to  confine  the  number  of  children  to  one  or 
two  has  been  frustrated.  Not  everybody  is  capable  of  sufficient 
self-control  especially  when  under  the  influence  of  the  powerful 
sensual  emotion. 

To  sum  up  I  look  upon  interrupted  intercourse  as  the  sim- 
plest preventive  measure  but  it  is  neither  harmless  nor  reliable 
enough  to  justify  its  being  recommended  as  the  best  in  all  cases. 

Vaginal  irrigations  and  antiseptic  introduc- 
tions.— As  decidedly  less  reliable  we  must  regard  vaginal  irri- 
gations with  antiseptic  solutions  and  the  introduction  into  the 
vagina  of  suppositories  or  small  sponges,1  etc.  impregnated  with 
disinfecting  substances.  The  complaints  which  have  reached 
me  to  the  effect  that  neither  most  carefully  executed  and  almost 
fatiguing  syringing  nor  the  latest  Parisian  Safety-Spongelets 
have  succeeded  in  warding  off  most  undesirable  events  are  too 
numerous  for  me  not  to  offer  the  strongest  opposition  to  con- 
trary assertions.  Rohleder  hits  the  mark  when  he  speaks  of 
Unsafety  Spongelets  (Unsicherheits-Schaemmchen). 

As  to  the  effect  of  vaginal  powder-insufflators  I  cannot  speak 
from  experience  but  judging  from  the  opinions  of  others  I  very 
much  doubt  whether  they  are  capable  of  killing  the  spermatozoa 
absolutely.  Not  a  few  women  especially  nulliparae  consider  all 
these  proceedings  as  "horrid,"  others  owe  to  them  more  or  less 
serious  complaints. 

Occlusive  pessaries. — I  have  almost  exactly  the  same 
opinion  with  respect  to  occlusive  pessaries  though  they  as  well  as 
remedies  of  the  last-mentioned  group  are  free  from  the  occasional 
inconveniences  of  interrupted  intercourse.  In  any  case  I  think 
they  show  very  little  consideration  to  the  wife's  comfort.  I  can- 
not possibly  enter  here  into  a  detailed  description  of  the  various 


1Perhaps  better  results  may  be  expected  from  the  remedy  recently  rec- 
ommended by  Feibes  under  the  name  of  "Protector"  as  a  prophylactic 
against  infectious  venereal  diseases,  with  which  we  are  not  concerned  here. 
It  reminds  one  of  a  lubricant  (Catheterpurin)  and  it  possesses  on  account  of 
its  high  percentage  of  salicylate  of  mercury  really  excellent  antiseptic  prop- 
erties without  being  markedly  irritant. 


238  HEALTH,  DISEASE,  MARRIAGE 

apparatuses.  I  have  repeatedly  seen  modifications  of  the  well- 
known  and  ingeniously  constructed  occlusive  pessary  of  Men- 
singa-Hasse  (rubber  hemisphere  with  steel  ring)  but  they  all 
suffer  from  the  defect  as  pointed  out  by  Kisch  and  others  that 
their  introduction  requires  as  a  rule  a  skilled  hand1  and  that  they 
easily  get  out  of  position.  For  this  reason  I  agree  with 
Rohleder  in  not  considering  this  reliability  as  favourable  as  is 
assumed  by  some  even  experienced  gynaecologists.  My  own 
statistics  confirm  this  though  they  are  of  course  based  on  failures 
complained  of.  Some  of  my  patients  have  as  a  result  of  the 
constant  manipulations  acquired  painful  and  persistent  inflam- 
mations of  the  adnexa.  If  Ribbing  who  also  considers  these 
apparatuses  unreliable  and  injurious  thinks  that  most  educated 
European  women  feel  grieved  at  being  regarded  as  objects  of 
voluptuousness  he  certainly  goes  too  far,  seeing  that  in  the  vast 
majority  of  cases  the  precaution  is  made  use  of  after  a  full 
mutual  pre-arrangement.  I  do  not  take  here  into  consideration 
the  sick  wife  and  her  privileges.  Most  serious  consequences 
may  have  to  be  apprehended  in  her  case. 

Condom. — The  condom  is  on  the  contrary  relatively  the 
most  perfect  anti-conceptional  remedy  and  is  inferior  in  sim- 
plicity to  the  interrupted  form  of  intercourse  only,  a  not  very 
serious  disadvantage.  But  it  is  obviously  on  account  of  its 
comparative  trustworthiness — it  is  only  those  condoms  which 
are  made  of  poor  material  that  frequently  leave  one  in  the  lurch 
— of  its  most  perfect  harmlessness  to  both  partners  and  because 
of  its  considerate  nature  with  regard  to  the  wife  as  well  as  of 
its  relatively  cleanly  manipulation  generally  that  it  has  achieved 
its  present  enormous  popularity.2  As  to  its  composition  and 


'I  have  just  had  brought  under  my  notice  a  new  preservative  constructed 
by  Weissl,  the  introduction  of  which  may  be  "learned"  by  the  wife  under  the 
guidance  of  the  doctor,  although  it  appears  to  me  somewhat  complicated 
(speculum,  rubber  plate  with  spring  and  impregnated  cotton  wool  tampon). 

*So  as  to  give  a  drastic  idea  of  the  extent  of  the  practice  I  may  reveal 
that  ladies  belonging  to  the  highest  classes  frequently  bring  to  their  husbands 
enormous  quantities  when  returning  from  the  various  watering  places,  espe- 
cially in  foreign  countries ;  even  clergymen  ask  their  medical  advisers  for  the 
necessary  sources  of  supply,  and — horribile  dictu — not  infrequently  have  I 
seen  the  things  scattered  about  when  taking  a  walk  in  solitary  places.  I  do 
not  believe  that  most  of  these  preservatives  are  used  for  the  prevention  of 


SEXUAL  HYGIENE  IN  MARRIED  LIFE      239 

technique  or  as  to  its  examination  I  cannot  enter  here  into  details ; 
those  who  require  information  on  the  subject  are  referred  to  the 
circumstantial  account  of  Rohleder  (1.  c.)  in  connection  with 
the  observations  of  Ferdy  and  containing  also  some  remarkable 
additions  of  his  own.  I  must  however  protest  against  the  con- 
demnation of  rubber  condoms  in  favour  of  so-called  coecal 
condoms  and  must  state  definitely  that  I  have  hardly  ever  heard 
of  any  disturbing  or  injurious  effects  in  connection  with  the  use 
of  the  former,  particularly  as  regards  the  perfectly  finished, 
thin  and  yet  entirely  resistible  preparations.  I  admit  that  not  a 
few  husbands  or  wives  find  the  degree  of  excitement  is  consider- 
ably diminished  and  the  duration  of  the  act  prolonged1  but  the 
majority  declare  that  it  is  not  markedly  different  "from  before." 
This  discounts  somewhat  the  assertion  of  Beard  that  interrupted 
and  condomated  intercourse  are  equal  in  their  effect  and  that 
they  are  both  much  more  injurious  than  frequently  exercised 
"normal"  intercourse.  Loewenfeld  also  does  not  hesitate  to 
give  to  the  condom  the  preference  over  the  other  anti-concep- 
tional  procedures.  Even  Barucco  who  is  against  occlusive 
pessaries  and  other  preventive  measures  considers  the  condom 
as  the  least  injurious  appliance. 

On  the  whole,  having  some  years  ago  expressed  the  opinion 
that  those  who  suffer  through  performing  interrupted  inter- 
course should  use  condoms  I  have  now  to  modify  my  view  in  so 
far  as  to  declare  the  latter  method  absolutely  preferable  to  the 
former. 

On  the  other  hand  I  have  never  hesitated  in  condemning  un- 
restrictedly the  so-called  "exciting  condoms."  There  are  prob- 
ably few  medical  men  who  would  not  turn  away  in  disgust  from 


infectious  venereal  diseases.  In  any  case  the  condom  is  at  the  present  time  a 
very  considerable  factor  in  the  preventive  intercourse  of  married  people  and 
one  with  which  the  practitioner  has  to  reckon.  If  he  refuses  to  give  his 
advice  in  these  hygienically  important  matters,  who  else  shall  give  it? 

^his  is  probably  the  reason  why  some  husbands  apply  the  apparatus 
shortly  before  ejaculation  without  apparently  suffering  in  any  material  de- 
gree from  this  combination  with  interrupted  intercourse.  I  wish,  however, 
to  warn  against  the  use  of  "glans  condoms,"  which  are  reputed  hardly  to  in- 
terfere with  the  sensation.  All  those  which  have  been  brought  under  my 
notice  have  proved  unreliable  in  consequence  of  their  instability. 


24o  HEALTH,  DISEASE,  MARRIAGE 


dare  to  recommend — these  apparatuses  which  are  not 
meant  to  serve  any  other  purpose  than  to  increase  the  sexual 
pleasure  and  are  for  this  reason  retailed  secretly  and  in  an 
underhand  way.1  It  does  not  alter  the  case  in  the  least  that 
similar  exciting  arrangements  (ampallangs)  are  used  for  the 
same  purpose  by  various  wild  and  more  civilised  tribes  in  the 
shape  of  prickly  apparatuses  and  even  of  bristles  attached  to 
the  perforated  penis.  (Ploss  and  Bartels.) 

General  hygienic  measures.  —  With  these  obser- 
vations I  might  very  well  conclude  my  remarks  if  I  did  not 
think  it  advisable  to  mention  at  least  casually  a  few  more  general 
precautionary  measures  which  are  of  decisive  importance  in  the 
sexual  hygiene  of  the  married  state,  particularly  where  gradual 
transitions  to  real  pathologic  changes  in  the  sexual  functions 
of  the  active  man  become  noticeable.  With  these  changes  them- 
selves I  am  not  dealing  at  present  but  I  refer  especially  to  incli- 
nations towards  the  so-called  occupational  and  psychical  (moral) 
or  hypochondriac  and  relative  potency.  It  is  therefore  far  from 
my  purpose  to  enter  into  a  discussion  of  the  necessary  thera- 
peutics and  of  the  various  electrical,  hydropathic  and  other 
"anti-neurasthenic"  establishments.2  On  the  other  hand  I  believe 
I  am  right  in  laying  stress — apart  from  the  necessity  of  daily 
cleanliness  as  a  procedure  calculated  to  be  beneficial  in  the 
sexual  hygiene  of  the  married  state — upon  two  powerfully 
efficient  factors  namely  travelling  and  muscular  exercise.3 


'I  think  I  ought  to  mention  here  the  attitude  of  Adler  on  the  titillatio 
clitoridis  by  the  husband  in  cases  of  dyspareunia.  He  considers  this  remedy, 
which  van  Swieten  is  said  to  have  recommended  to  the  Empress  Maria 
Theresia  with  success,  as  permissible  advice.  I  am  not  inclined  to  absolutely 
contradict  this  author,  who  takes  a  serious  view  of  the  practitioner's  duty, 
especially  as  he  restricts  the  treatment  to  suitable  cases  and  demands  tact  and 
corresponding  intimacy  between  husband  and  wife,  but  I  am  rather  afraid 
that  it  is  in  substance  nothing  but  an  onanistic  manipulation  on  the  part  of 
the  husband  on  his  wife. 

'The  physical  treatment  of  such  cases  of  potency  as  well  as  the  dietetic 
is  elaborately  dealt  with  in  the  recent  work  of  Goldscheider  and  Jacob  and 
in  that  of  v.  Ley  den  and  Klemperer  just  issued,  respectively. 

"The  separation  of  young  husbands  from  doubtful  company,  the  discon- 
tinuation of  the  reading  of  pernicious  literature,  the  abandonment  of  las- 
civious recollections,  and  so  forth,  I  take,  of  course,  for  granted,  especially 
where  excessive  intercourse  and  its  dangers  are  threatening. 


SEXUAL  HYGIENE  IN  MARRIED  LIFE      241 

Holidays. — These  are  especially  as  conducted  now-a-days 
in  combination  if  at  all  beneficial  as  hygienic  measures  particu- 
larly so,  if  suitably  indulged  in,  in  just  those  cases  becoming 
more  and  more  frequent  where  potential  disturbances  not  imma- 
terial to  either  husband  or  wife  are  being  prepared  by  mental 
diversions  especially  such  as  are  constantly  created  by  the 
unhygienic  life  in  large  towns.  Where  the  mental  activity  and 
the  moral  exertion  necessitated  by  ambition,  want  or  passion 
either  in  businesss,  scientific  pursuits,  artistic  work  or  other 
vocations  are  over-employed  there  is  not  much  left  for  the 
sexual  intercourse  of  marriage.  It  is  in  such  cases  as  stated 
also  by  Eulenburg  and  v.  Gyurkovechky  more  or  less  emphati- 
cally that  travelling  shows  most  excellent  results ;  not  fatiguing 
travelling  but  comfortable  and  enjoyable  journeys  to  pretty 
places  without  books  or  other  material  of  study.  The  "procul 
negotiis"  is  indeed  an  essential  condition  if  the  hitherto 
"neglected"  wife  is  to  be  made  happy  on  these  excursions,  if  the 
diligent  scholar,  the  sedentary  and  meditating  lawyer,  the  over- 
worked medical  man  or  busy  merchant  is  to  regain  the  affection 
of  his  life-partner  whom  he  is  taking  to  foreign  climes,  to  the 
delights  of  nature  or  to  the  joyous  bustle  of  the  world  without. 
The  new  impressions,  the  relaxation,  the  pleasure  of  fresh 
society  and  last  but  not  least  the  table  d'hote  in  conjunction  with 
a  moderate  allowance  of  alcohol  will  do  the  rest.  Though 
under  ordinary  circumstances  the  medical  practitioner  should  not 
be  at  all  lax  in  this  last  respect  and  though  he  should  warn 
against  over-indulgence  which  is  particularly  harmful  in  sexual 
hygiene  he  will  not  do  wrong  in  such  cases  to  allow  a  little 
latitude  of  golden  indiscretion.1 

Muscular  exercise. — Of  the  various  forms  of  mus- 
cular exercise,  walking,  mountain  climbing  and  gymnastics  are 
for  obvious  reasons  the  most  frequently  used.  I  cannot  however 
resist  the  temptation  to  say  a  few  words  of  praise  in  favour  of 
cycling,  a  fine  sport  not  as  yet  sufficiently  cultivated,  provided  of 
course  it  is  carried  out  within  hygienic  limits.  It  is  just  because  it 


*It  is  hardly  necessary  to  draw  attention  to  the  high  degree  of  harmful 
sexual  desire  engendered  by  alcoholic  excess,  especially  when  in  the  form  of 
drinking  bouts.  (Eulenburg.) 


242  HEALTH,  DISEASE,  MARRIAGE 

enables  the  cyclist  to  cover  long  distances  by  easy  muscular 
exercise  and  thus  get  into  the  fresh  air  that  it  is  so  vastly  supe- 
rior to  indoor  gymnastics  and  automobilism.  In  addition  to  this 
advantage  which  fosters  courage  and  self-reliance  it  possesses 
the  unique  merit — and  this  brings  it  into  touch  with  my  present 
subject — that  as  first  pointed  out  by  Bertz  in  his  "Philosophy 
of  Cycling"  it  produces  a  sub-division  of  activity  in  the  cerebral 
centres  of  the  cycling  brain-worker.  Finally,  cycling  is  easily 
and  quickly  learnt  even  by  elderly  people,  as  I  can  testify  from 
personal  experience.1  Its  disadvantages  especially  with  regard 
to  sexual  hygiene  have  been  unduly  exaggerated. 

Psychical  treatment. — As  regards  finally  the  attitude 
of  the  physician  in  the  presence  of  light  manifestations  of  purely 
psychical  disturbances  of  potency  and  their  allied  forms  to 
which  young  and  newly  married  people  are  as  is  well  known 
so  much  subject,  it  is  well  to  remember  that  a  few  rational, 
firm  and  sympathetic  words  of  encouragement  accompanied  by 
a  little  pertinent  information  are  very  often  sufficient  to  re-es- 
tablish confidence  in  one's  own  capability  and  self-reliance,  and 
to  avert  unhappy  marriages,  childlessness  or  divorce  proceed- 
ings. On  the  other  hand  we  must  bear  in  mind  the  experience 
already  mentioned  that  on  account  of  the  peculiar  whims  of 
sexual  life  not  infrequently  prohibition  of  conjugal  connection 
is  followed  by  most  satisfactory  results,  inasmuch  as  the  young 
husband  who  possesses  the  necessary  self-confidence  violates  the 
prohibition.  His  imagination  however  must  be  kept  free  from 
sexual  affairs. 

But  no  matter  whether  there  are  such  frequently  seen 
troubles  or  whether  normal  circumstances  prevail,  the  husband 
shall  as  Ribbing  puts  it  request  as  a  favour  and  not  demand  as  a 
right  sexual  connection  with  his  wife;  provided  always  that  the 
latter  is  sufficiently  considerate  to  her  life-partner  in  taking  into 
account  his  moral  and  hygienic  privileges  and  in  her  contribu- 
ting her  share  to  render  their  joint  married  life  a  happy  and 
harmonious  union. 


'For  details  see  my  article  "Appreciation  of  cycling  from  the  medical 
point  of  view,"  Deutsche  Aerzte-Zeitung,  1900,  No.  ij. 


VII 


Menstruation,    Pregnancy,    Child-bed,    and 
Lactation  in   Relation    to   Marriage 


VII 

MENSTRUATION,      PREGNANCY,      CHILD- 
BED, AND    LACTATION  IN  RELATION 
TO    MARRIAGE 

By  Professor  R.  Kossmann  (Berlin) 

The  most  important  work  on  the  diseases  of  women  which 
has  been  preserved  to  us  from  ancient  times,  that  of  Soranus 
of  Ephesus  says :  r^itlg- ^isvroi  Kara,  $VGLV  Idia  •ntt&ri  Xeyopev  ywcan&v 
otov  r<5  ffvXXappavetv  KoCl  anoriKTeiv  KCU  yaXaitrovpyelv,  el  ravra  /JovAerae 
rig  ra  Ipya.  na$i)  Ttpoaayopevetv.  "We  call  such  special  diseases  of 
women  "natural"  as  f.  i.  conception  (pregnancy)  childbirth 
and  the  secretion  of  milk  provided  such  functions  can  be  at  all 
called  diseases." 

It  is  therefore  seen  that  there  were  already  thousands  of 
years  ago  men  who  knew  that  the  distinction  between  what  we 
generally  call  "normal"  (or  physiological)  and  "pathological" 
is  not  identical  with  the  distinction  between  health  and  disease. 
There  are  "natural"  conditions  in  the  normal  course  of  a 
woman's  life  which  may  well  be  called  diseases  because  they  are 
unavoidably  associated  with  pain  and  functional  disturbances 
or  at  least  with  diminished  resistibility.  To  these  belong  as 
Soranus  correctly  says  pregnancy,  childbirth  and  lactation  but 
we  may  also  add  to  the  list  child-bed  and  menstruation,  the 
latter  of  which  is  KOT'  ^o^v  called  by  the  female  sex  "being 
unwell."  That  these  "physiological  diseases"  their  influence 
upon  the  married  state  and  the  influence  of  the  latter  upon  them 
deserve  a  special  chapter  in  this  work  the  reader  will  readily 
grant. 

Menstruation. — Beginning  with  menstruation  we  find 
that  even  where  the  phenomena  associated  with  it  do  not  exceed 
the  normal  limits  there  are  still  a  number  of  symptoms  which 


246  HEALTH,  DISEASE,  MARRIAGE 

may  be  regarded  as  a  disordered  state  of  health  or  at  least  as 
disturbances  of  the  subjective  condition.     Before  the  commence- 
ment of  the  sanguineous  discharge  the  woman  experiences  pain 
(although  moderate  in  degree)  in  the  loins  and  in  the  back,  a 
sensation  of  heaviness  and  downward  pressure  in  the  abdomen, 
tention  in  the  external  genitals  and  often  also  in  the  breasts. 
All    this    is    produced   by    a    congestion    of    blood    which    is 
easily  visible  and  which  causes  a  tumefaction  of  the  labia, 
vagina,  uterus  and  breasts  and  is  most  probably  also  the  reason 
of  the  increased  blood  pressure  in  the  ovaries  which  causes 
the  Graafian  follicle  to  burst.     Accompanying  these  symptoms 
there  is  an  increased  irritability  of  the  vasomotor  and  often  also 
of  the  sensory  nerves,  an  excitation  of  the  sexual  faculty  and  a 
depression  of  the  mental  condition.    Even  if  we  admit  that  this 
change  in  the  subjective  state  has  reached  its  modern  average 
extent  by  the  pampering  of  our  race  it  is  yet  evident  from  what 
we  observe  in  mammalian  animals  that  the  main  troubles  con- 
nected with  menstruation  are  unavoidable  and  normal.   It  would 
seem  that  the  congestion  in  the  generative  organs  is  necessary  for 
the  purpose  of  liberating  the  ovum  from  its  follicle  and  of  fixing 
it  in  the  uterine  mucous  membrane;  the  increase  in  the  sexual 
desire  towards  the  end  of  menstruation  assures  in  animals  the 
exercise  of  copulation  at  a  time  most  favourable  for  the  impreg- 
nation of  the  ovum  and  is  in  man  probably  an  inheritance  from 
his  animal  ancestors;  the  mental  depression,  finally,  and  the 
nervous  irritability  are  possibly  caused  by  the  unnatural  sexual 
abstinence  which  has  become  a  human  institution  through  the 
dictates  of  religion  or  morality.     We  are  therefore  justified  in 
looking  upon  these  disturbances  in  so  far  as  they  do  not  exceed 
materially  the  average  condition  as  Kara.    <f>vffiv  na$r),  as  physio- 
logical ailments,  so  that  though  they  are  morbid  phenomena 
in  the  sense  of  this  book  they  yet  require  to  be  considered  as  a 
particular  group  distinct  from  genuine  pathologic  disorders. 

Concerning  the  importance  of  menstruation  in  the  married 
state  the  fact  just  mentioned  that  sexual  intercourse  is  by 
established  custom  suspended  during  menstruation  forms  the 
principal  factor.  As  the  sexual  desire  in  the  woman  is  increased 
towards  the  end  of  menstruation  this  sexual  abstinence  is 


MENSTRUATION  247 

undoubtedly  a  proceeding  antagonistic  to  the  natural  instinct. 
Though  it  is  in  accordance  with  universal  custom  and  though 
it  is  even  declared  by  the  Parsee,  Mosaic,  Mohammedan  and 
possibly  also  other  religions  as  a  divine  commandment  this  is 
probably  a  result  of  the  view  prevalent  among  the  ancient 
civilised  nations  that  the  menstrual  blood  and  consequently  the 
menstruating  woman  is  unclean.  The  old  Parsees  used  to 
confine  their  menstruating  women  in  closed  rooms  so  that  they 
should  not  come  in  contact  with  other  people;  the  Jews  were 
not  only  prohibited  from  having  intercourse  during  menstru- 
ation this  being  a  criminal  offence  punished  with  the  death  of 
both  parties,  but  the  couch  of  a  menstruating  woman  and  every- 
thing that  came  in  contact  with  it  were  also  considered  unclean. 
(3.  Mos.  15.  V.  20-23.)  The  Chinese  and  Japanese  have 
similar  customs  and  the  same  may  be  said  of  almost  all 
half-civilised  races.  Numerous  notices  exist  on  the  subject  as 
f.  i.  in  the  work  of  Ploss  and  Bartels.  (Das  Weib  in  der  Natur- 
und  Voelkerkunde.  yth  edit.  Leipsic,  1902.  I.,  pp.  420  sq.) 
Even  scientific  Medicine  adapted  itself  to  this  view  and 
came  to  look  upon  the  uterus  as  an  organ  of  excretion  whose 
function  consisted  in  eliminating  the  injurious  products  of 
metabolism;  hence  the  classic  designations  of  what  we  call 
to-day  "menstruation"  as  "re  «ai9apa^"and  "purgatio,"  (men- 
strua), which  have  retained  their  equivalent  in  modern 
languages  under  the  name  "monthly  cleaning."  Most  extra- 
ordinary notions  of  the  dreadful  poisonousness  of  the  menstrual 
blood  penetrated  from  the  popular  superstition  of  oriental 
nations  into  the  writings  of  Plinius  and  Columella  and  from 
these  into  the  medical  literature  of  the  middle-ages.  Seed 
coming  in  contact  with  menstrual  blood  was  supposed  to  turn 
barren;  fruit  would  drop  from  the  trees  against  the  foot  of 
which  a  menstruating  woman  had  been  leaning;  knives  would 
get  blunt  by  being  breathed  upon  by  them ;  mirrors  tarnished  if 
looked  into  by  them.  The  rabies  of  dogs  was  attributed  to  the 
partaking  of  menstrual  blood.  The  fermentation  of  new  wine 
was  sure  to  be  interfered  with  if  a  menstruating  woman  entered 
the  cellar.  (This  superstition  is  still  prevalent  in  the  Rhine 
district  and  also  in  other  parts.)  Finally  intercourse  with  a 


248  HEALTH,  DISEASE,  MARRIAGE 

menstruating  woman  was  supposed  to  be  productive  of 
leprosy. 

Such  deep-rooted  superstition,  to  which  was  afterwards 
added  the  disgust  of  sensible  men  at  sullying  their  bodies  with 
blood,  resulted  in  spite  of  the  indifferent  attitude  of  the  Catholic 
Church  (the  moral  theology  of  Alphonse  of  Liguori  permits 
distinctly  intercourse  with  a  menstruating  woman)  in  establishing 
abstention  during  the  monthly  periods  as  an  universal  practice. 

Marriage  must  take  this  into  account.  Hence  the  fairly 
general  custom  of  arranging  the  wedding-day  on  a  date  not  very 
far  removed  from  the  cessation  of  the  preceding  menstruation. 
The  neglect  of  this  precaution  may  lead  to  most  disagreeable 
mental  depressions  by  compelling  the  newly-married  people 
to  abstain  from  intercourse  at  a  time  when  the  sexual  excitement 
is  at  its  highest. 

It  is  of  course  questionable  whether  this  abstention  is  in 
reality  an  hygienic  necessity  or  only  a  very  ancient  mistaken 
prejudice.  There  are  weighty  reasons  in  favour  of  the  latter 
alternative.  That  the  rut  of  animals  corresponds  to  human 
menstruation  in  its  main  points,  that  is,  in  the  periodical  con- 
gestion of  the  genital  organs  and  the  bursting  of  the  Graafian 
follicle,  can  no  longer  be  denied  as  it  was  formerly  done.1  But 
in  animals  which  possess  a  rutting  period  intercourse  takes  place 
just  during  such  period  and  in  most  of  them  during  such  period 
only,  as  at  other  times  the  females  experience  no  sexual  desire 
and  do  not  exercise  any  attraction  upon  the  males.  Even  if 
we  ignore  the  Darwinian  theory  altogether  we  cannot  quite 
conceive  how  an  homologous  process  could  take  place  in  homol- 
ogous organs  of  most  living  creatures  naturally  and  even  neces- 
sarily as  a  means  of  propagating  the  species,  and  yet  that  the  same 
process  should  in  the  case  of  the  genus  homo  only  be  unnatural 
and  injurious.  Moreover,  the  instinct  which  compels  rutting 
animals  irresistibly  to  copulate  is  almost  without  an  exception 
present  in  women  in  the  form  of  a  distinctly  increased  sexual 
desire,  though  like  all  other  human  instincts  it  is  successfully 
combated  by  various  psychical  and  somatic  inhibitory  processes. 


*( Editor's  Note:    Compare  this  with  p.  225  in  the  article  by  Prof.  Fiir- 
bringer,  Chapter  VI.) 


MENSTRUATION  249 

It  would  be  remarkable  in  the  highest  degree  if  we  really  had 
before  us  a  natural  desire  distinguished  by  its  exceptional  char- 
acter of  a  normal  instinct  which  it  is  injurious  to  gratify.  Such 
an  hypothesis  wanting  both  in  analogy  and  probability  cannot  be 
accepted  as  indisputable  on  the  strength  of  religious  commands, 
or  popular  beliefs,  but  requires  most  careful  examination.  Such 
an  examination  is  irt  so  far  of  considerable  importance  from  the 
point  of  view  of  the  married  state  as  it  is  quite  possible  and  from 
a  comparison  with  other  numerous  animals  even  probable  that 
the  sexual  frigidity  of  so  many  married  women,  which  is  so 
disturbing  an  element  in  the  reciprocal  relationship  between 
them  and  their  husbands  and  often  a  cause  of  conjugal  unfruit- 
fulness,  is  only  an  extra-menstrual  one.  In  cases  where  there 
is  reason  to  suspect  such  a  state  of  affairs  the  practitioner  will 
perhaps  do  well  to  encourage  an  attempt  in  this  direction.  The 
aesthetic  dislike  of  a  possible  pollution  with  blood  can  be 
removed  by  a  suitable  lukewarm  irrigation.  Experiments  on 
animals  and  observations  in  man  have  shown  that  the  highest 
point  of  the  sexual  desire  is  reached  towards  the  end  of  menstru- 
ation— it  might  therefore  be  advisable  to  prefer  that  part  of 
the  period.  This  question  is  moreover  of  importance  perhaps 
from  another  standpoint  as  well.  As  has  already  been  men- 
tioned it  is  usual  with  many  women  to  exhibit  towards  the  end 
of  menstruation  a  noticeable  or  even  a  very  disturbing  mental 
depression  and  a  marked  disagreeableness  of  temper.  The 
inference  is  therefore  justified  as  indicated  above  that  this 
disturbed  condition  is  not  unconnected  with  the  suppression — 
demanded  by  custom — of  a  natural  desire.  Therefore  in  mar- 
riages where  these  disturbances  threaten  to  assume  considerable 
proportions  an  attempt  at  intramenstrual  intercourse  would  also 
be  indicated.1  In  any  case  the  practitioner  should  make  it  his 
duty,  whenever  the  opportunity  arises,  to  instruct  the  husband 
as  to  the  naturalness  and  necessity  of  the  nervous  irritability 
during  menstruation.  The  closely  intimate  relations  between 


'See  footnote,  p.  225,  in  the  article  of  Prof.  Fiirbringer.  I  must  adhere  to 
these  views  with  regard  to  the  rut  of  animals  and  intercourse  during  menstru- 
ation, opposed  though  they  are  to  Furbringer's  opinions.  No  one  who  re- 
gards the  periodical  hypersemia  and  the  bursting  of  the  Graafian  follicle  as 
the  main  essence  of  menstruation  can  deny  its  identity  with  the  rut  of  animals. 


250  HEALTH,  DISEASE,  MARRIAGE 

two  individuals  who  must  be  indulgent  to  and  understand  each 
other,  if  the  marriage  is  to  be  a  happy  one  and,  on  the  other 
hand  the  monotony  of  the  wifely  duties  connected  with  the 
household,  cannot  help  being  a  plentiful  source  of  conflicts 
during  this  period  of  irritability,  and  the  practitioner  should 
inform  the  husband  that  he  must  endeavour  to  avoid  these 
conflicts.  He  must  treat  his  menstruating  wife  as  if  she  were 
recovering  from  some  slight  illness,  that  is,  he  must  attempt 
to  diminish  the  extent  of  the  house-duties,  he  must  keep  from 
her  worry,  bad  news  or  sorrow,  he  must  not  retort  on  occa- 
sional outbreaks  of  unjustified  irritability  but  rather  avert  them 
good-humou redly.  It  is  almost  always  during  menstruation  that 
the  first  clouds  appear  on  the  matrimonial  horizon ;  the  husband 
who  is  aware  of  the  importance  of  these  "critical  days"  will 
know  how  to  take  the  necessary  means  for  their  prevention. 

Pregnancy. — We  will  now  consider  the  second  of  the 
physiological  diseases,  namely  pregnancy. 

If  pregnancy  occasions  in  woman  a  certain  amount  of  bodily 
suffering,  this  is  principally  due  to  the  fact  that  the  foetus  lives 
as  a  parasite  at  the  expense  of  the  mother,  that  it  consequently 
draws  from  her  the  entire  material  required  not  only  for  the 
formation  of  its  own  body  (with  the  exception  of  the  impreg- 
nating germinal  cell)  but  also  for  her  own  metabolism.  There 
is  thus  caused  in  the  first  instance  a  more  or  less  complete 
exhaustion  of  the  reserve  substances  stored  up  in  the  maternal 
body,  and  secondly  an  increased  demand  of  nourishment  and  of 
oxygen.  The  necessary  consequence  of  the  satisfaction  of  this 
demand  is  an  increased  activity  on  the  part  of  the  digestive  and 
secreting  organs — the  stomach,  the  intestines  and  the  kidneys. 
There  is  further  developed  in  conformity  with  these  increased 
requirements  an  automatically  working  correlation  between  cer- 
tain organs  which  causes  the  heart  of  the  pregnant  woman  in 
particular  to  perform  a  greater  amount  of  work.  Finally  preg- 
nancy creates  disturbances  of  a  purely  mechanical  nature.  The 
increasing  weight  of  the  pregnant  uterus  interferes  with  the 
movements  of  the  body  and  is  a  constant  burden  to  the  dorsal 
region.  The  greater  voluminousness  stretches  the  abdominal 
walls,  causes  sub-cutaneous  ruptures  in  them,  produces  an 


PREGNANCY  251 

over-tension  in  the  abdominal  muscles  which  prevents  a  re-es- 
tablishment of  their  original  tonicity,  while  the  abdominal  pres- 
sure is  during  pregnancy  diminished.  The  bladder  is  also 
encroached  upon  and  its  capacity  decreased ;  there  is  an  increased 
pressure  upon  the  intestines  and  especially  upon  the  rectum  the 
function  of  which  is  rendered  more  difficult;  the  sympathetic 
ganglia  in  the  abdomen  are  irritated  through  the  tension  and 
displacement  of  the  mesentery.  Finally  the  intra-abdominal 
pressure  occasioned  by  the  crowded  state  of  the  organs  hinders 
the  return  of  the  blood  into  the  large  abdominal  veins  and  pro- 
duces a  congestion  in  the  regions  supplying  them. 

It  is  certainly  true  that  the  organism  is  capable  of  adapting 
itself  to  a  certain  extent  to  these  purely  objective  changes  in 
the  conditions.  Nevertheless  this  is  only  partly  the  case,  and  it 
is  more  difficult  to  draw  the  line  where  the  phenomena  cease  to 
be  normal  and  begin  to  become  morbid,  than  even  in  pregnancy. 
The  increased  consumption  of  the  reserve  material  is  bound 
under  all  circumstances  to  diminish  the  resistibility  of  the  body 
against  injurious  influences.  As  a  matter  of  fact  it  is  well  known 
that  pregnant  women  possess  a  lesser  resistibility  against 
diseases  of  all  kinds.  The  necessarily  increased  consumption 
of  food  and  of  oxygen  easily  produces  digestive  disturbances, 
and  physical  exertion  especially  in  climbing  even  if  it  does  not 
greatly  exceed  the  normal  allowance  is  apt  to  give  rise  to  a 
dilatation  of  the  left  ventricle.  But  where  the  quantity  of  food 
consumed  or  assimilated  is  not  sufficient  to  compensate  for  the 
greater  expenditure,  the  nutrition  of  the  body  suffers,  emaciation 
and  hydraemia  (serous  plethora)  appears  in  spite  of  the 
attempts  of  the  organisms  at  compensation,  as  proved  by  an 
increase  in  the  number  of  white  corpuscles  in  the  blood  (physio- 
logical leucocytosis  of  Virchow.)  The  overloading  of  the 
blood  with  the  end-products  of  the  metabolism  of  two  indi- 
viduals, the  maternal  and  the  foetal,  is  capable,  where  the 
activity  of  the  kidneys  is  somewhat  diminished  although  they 
act  otherwise  perfectly  normally,  of  producing  albuminuria  on 
the  one  hand  and  uraemia  on  the  other.  We  may  here  probably 
also  look  for  the  indirect  cause  of  accumulations  of  pigment — 
consequent  on  the  destruction  of  a  large  number  of  red  blood- 


252  HEALTH,  DISEASE,  MARRIAGE 

corpuscles — present  not  only  in  the  areolae  of  the  breasts  and 
in  the  linea  alba  under  normal  circumstances  but  also  very  often, 
and  sometimes  with  disfiguring  results,  under  the  name  of 
"Chloasma  Uterinum"  on  the  faces  of  pregnant  women.  The 
increased  demand  on  the  striped  muscles  of  the  body  arising 
from  the  growing  weight  of  the  pregnant  uterus  lowers  the 
working  ability  of  the  woman  and  soon  causes,  where  the 
amount  of  work  performed  cannot  be  reduced  below  the  usual 
quantity,  overfatigue  and  its  consequences.  The  slow  action  of 
the  bowels  produced  by  the  overtension  of  the  abdominal  mus- 
cles and  the  compression  of  the  rectum  increases  the  inclination 
already  existing  to  digestive  disturbances,  interferes  therefore 
with  the  assimilation  of  food  and  deteriorates  the  quality  of 
the  blood.  The  diminished  capacity  of  the  bladder  occasions 
subjective  discomfort  but  interferes  also  with  sleep  and  is  under 
our  modern  arrangements  which  do  not  provide  sufficient  oppor- 
tunities for  women  to  satisfy  immediately  the  desire  to  mictu- 
rate  a  source  of  considerable  inconvenience.  The  increased 
pressure  upon  the  abdominal  veins  causes  varicosities  and 
oedemata  especially  in  the  genitals  and  in  the  lower  extremities. 
It  is  not  only  the  sympathetic  centres  which  become  irritated 
through  mechanical  causes;  several  of  the  disturbances  men- 
tioned and  particularly  the  indigestion,  the  exhaustion  through 
insufficient  food  and  through  hydraemia,  the  retention  of  inju- 
rious substances  in  the  blood  through  deficient  action  of  the 
kidneys  combine  among  themselves  and  also  with  purely  psychi- 
cal influences  and  thus  give  rise  to  considerable  nervous  dis- 
orders. Among  those  which  are  so  frequent  that  they  are  often 
regarded  as  unavoidable  and  non-pathological  symptoms  are  the 
irritability  of  the  vaso-motor  nervous  apparatus  which  shows 
itself  chiefly  in  the  form  of  palpitation,  congestion,  giddiness 
and  syncope;  the  increased  sensibility  of  the  cutaneous  nerves; 
nausea  and  frequent  vomiting;  functional  disturbances  in  the 
Organs  of  the  Senses  (amblyopia,  partial  deafness,  perverse 
sensations  of  taste  and  smell,  hyperaesthesias  and  anaesthesias). 
Even  without  any  demonstrable  special  predisposition  or  with- 
out any  demonstrable  complications  of  the  pregnancy  there  may 
occur  also  psychical  derangements,  principally  in  the  form  of 


PREGNANCY  253 

marked  psychical  irritability  depression  and  melancholia  or  in 
the  shape  of  perverse  longings,  (niooa.,  or  "picca"  of  the 
ancients)  which  cause  a  detestation  of  ordinary  food  and  a 
desire  for  most  unpalatable  things. 

All  these  disturbed  conditions  which,  though  not  by  any 
means  natural,  are  nevertheless  exceedingly  frequent  accompani- 
ments of  pregnancy,  are  of  enormous  importance  to  the  married 
state.  Where  a  marriage  has  been  contracted  in  the  expectation 
that  the  wife  will  participate  in  the  earning  of  the  livelihood, 
pregnancy  compels  her  at  least  during  a  part  of  its  duration  to 
desist  from  such  participation  wholly  or  partly  on  account  of 
her  diminished  working  ability.  But  even  the  fulfilment  of  the 
ordinary  house-duties  devolving  upon  the  majority  of  wives  may 
become  so  difficult  that  the  household  is  bound  to  suffer.  The 
lesser  resistibility  against  disease  often  renders  the  wife  totally 
unable  to  do  any  work  and  even  necessitates  attendance  upon  her 
on  the  part  of  other  people.  Moreover  the  psychical  irrita- 
bility on  the  one  hand  and  the  depression  or  possibly  the  melan- 
cholia on  the  other  make  her  more  or  less  incapable  for  other 
work  also  besides  mere  mechanical  duties.  The  proper  super- 
vision of  the  entire  household,  the  firm  but  just  management 
of  the  domestic  servants,  the  resolute  bringing  up  of  the  chil- 
dren, the  considerate  and  patient  treatment  of  the  husband  who 
comes  home  tired  from  his  hard  daily  work;  all  these  conjugal 
duties  which  are  no  doubt  of  the  highest  importance  may  suffer 
considerable  neglect  in  consequence  of  such  psychical  disturb- 
ances of  pregnancy. 

Against  all  these  facts  stands  out  prominently  the  circum- 
stance that  the  procreation  of  children  is  from  the  standpoint 
of  morality  as  well  as  from  that  of  patriotism  the  main  object 
of  marriage,  and  that  maternal  happiness  is  under  anything 
like  normal  conditions  the  highest  and  most  ennobling  sentiment 
of  woman.  For  this  reason  conjugal  pregnancy  ought  never  to 
be  renounced  willingly  and  on  account  of  the  disadvantages 
and  dangers  mentioned  above.  It  so  happens  moreover  that 
such  a  renunciation  is  only  possible  by  abstaining  from  sexual 
intercourse  altogether  or  by  the  adoption  of  certain  measures 
preventing  conception.  But  such  an  abstention  is  apart  from 


254  HEALTH,  DISEASE,  MARRIAGE 

the  above  indicated  moral  and  patriotic  motives  very  much  to 
be  deprecated.  Woman  is  seldom  so  frigid  as  to  desire  sexual 
continence  or  even  to  be  indifferent  in  the  matter — even  if  she 
maintains  this  to  be  the  case.  She  will  generally  regard  her 
husband's  abstention  as  a  serious  neglect,  will  direct  her  attention 
to  other  men  and  may  even  be  driven  by  circumstances  to 
commit  adultery ;  towards  her  husband  she  will  become  careless 
and  inconsiderate.  As  far  as  he  is  concerned,  it  is  relatively 
seldom  that  he  will  abstain  from  sexual  connection  entirely;1 
in  most  cases  he  will  look  for  it  elsewhere,  and  thus  be  misled 
into  neglecting  his  home  and  leading  a  dissipated  life;  this 
would  tend  to  undermine  his  health  upon  which  the  welfare  of 
his  family  depends.  And  as  regards  anti-conceptional  pro- 
cedures, it  may  be  said  that  those  which  are  in  any  way  reliable 
are  absolutely  injurious  to  health  because  of  the  abnormal  con- 
gestion in  the  genital  organs  and  of  the  excessive  irritation  of 
the  nervous  system  which  they  produce,  and  also  because  the 
gratification  required  for  the  removal  of  that  congestion  and 
for  the  appeasement  of  that  irritation — that  is  the  ejaculatory 
act  in  man,  and  peristaltic  movements  in  the  uterus  and  in  the 
tubes — is  delayed  or  even  absent  altogether.2  The  preventive 

^Compare  this  with  p.  225  in  Furbringer's  article.  I  am  in  complete 
agreement  with  Fiirbringer  and  the  authorities  he  quotes  in  so  far  as  they 
consider  sexual  continence  in  man  in  no  way  injurious  to  health.  But  most 
married  men,  accustomed  as  they  are  to  a  regular  performance  of  the  sexual 
act,  will  find  it  impossible  to  break  with  the  custom  suddenly  and  for  any 
length  of  time. 

2See  p.  233  in  Furbringer's  article.  As  regards  the  congressus  interrup- 
tus,  it  is  not  likely  to  be  injurious  to  the  husband  if  it  is  exercised  in  such 
a  way  as  to  permit  ejaculation  to  take  place;  in  this  case,  however,  it  often 
misses  its  object,  as  the  interruption  occurs  too  late.  As  to  the  wife,  the  in- 
terruption will  certainly  do  her  no  harm  if  she  is  of  a  frigid  temperament, 
but  I  consider  it  very  harmful  if  in  the  case  of  a  wife  who  is  not  frigid  the 
interruption  takes  place  before  the  orgasm  has  reached  its  highest  point.  I 
have  very  often  been  able  to  remove  quickly  hyperaemia,  leucorrhoea  and 
nervous  depression  in  married  women  by  prohibiting  interrupted  intercourse. 
Concerning  the  condom,  the  diminution  in  the  pleasurable  sensation  which  it 
causes  varies  in  different  individuals ;  however,  this  diminution  is  sometimes 
very  considerable,  and  in  such  a  case,  especialy  if  it  affects  only  the  hus- 
band or  only  the  wife,  the  remedy  is  certainly  also  injurious,  both  to  the 
bodily  and  the  moral  constitution.  As  regards  the  other  preventive  meas- 
ures I  am  in  full  agreement  with  Fiirbringer. 


PREGNANCY  255 

measure  which  consists  in  restricting  the  intercourse  to  the  third 
week  after  the  commencement  of  menstruation  is  probably  the 
only  one  which  has  not  these  disadvantages;  but  the  question 
arises  whether  this  partial  continence  would  not  have  in  many 
marriages  almost  the  same  results  as  those  mentioned  above. 
There  remains  therefore  for  the  amelioration  of  the  injuri- 
ous accompaniments  of  pregnancy  nothing  but  a  rational 
hygiene  of  pregnancy.  What  this  hygiene  dictates  is  clear  from 
what  has  been  said.  In  the  first  instance  it  is  evident  that  a 
marriage  which  depends  on  the  constant  physical  employment 
on  the  part  of  the  wife  is  wrong  in  principle.  There  is  every 
justification  for  the  proposal  to  introduce  legislation  restricting 
the  employment  of  pregnant  women  in  certain  trades,  and  the 
idea  of  a  pregnancy-insurance  which  shall  enable  pregnant 
married  women  to  receive  during  their  pregnancy  amounts  cor- 
responding to  their  loss  of  wages  deserves  every  encouragement. 
It  were  highly  desirable  that  such  amounts  should  include  also 
stated  sums  for  the  purpose  of  providing  the  pregnant  woman 
with  some  domestic  assistance,  so  that  she  should  be  spared  such 
hard  work  as  carrying  coal  or  water,  etc.  where  she  is  in  the 
habit  of  doing  so  under  normal  circumstances.  There  is  also 
great  necessity  to  protect  pregnant  women  against  infection  and 
against  the  vicissitudes  of  the  weather.  Where  there  is  a  pre- 
disposition to  certain  diseases  and  especially  to  affections  of  the 
kidneys,  lungs,  heart  or  the  nervous  system  a  suitable  prophy- 
laxis must  be  instituted  and  where  symptoms  of  these  diseases 
have  already  made  their  appearance  the  required  treatment 
must  be  undertaken  with  particular  care  or  the  pregnancy  deter- 
mined if  the  necessity  arises.  As  to  what  "necessity"  means  in 
this  connection  there  is  no  unanimity  of  opinion.  The  law- 
books  do  not  contain  any  definite  enactments  declaring  when 
the  induction  of  abortion  by  medical  men  is  exempt  from  punish- 
ment. The  Catholic  Church  has  only  recently  condemned  arti- 
ficial abortion  under  all  circumstances  even  where  it  is  the  only 
means  of  saving  the  mother's  life.  Most  German  doctors  how- 
ever consider  it  permissible  or  even  indicated  as  a  life-saving 
remedy.  Some  go  even  so  far  as  to  demand  it  in  cases  where 
there  is  danger  of  considerable  aggravation  of  a  somatic  or 


256  HEALTH,  DISEASE,  MARRIAGE 

psychical  disease  in  a  pregnant  woman.  Under  such  circum- 
stances every  practitioner  must  for  the  present  be  responsible 
to  his  own  conscience  for  the  decision  to  be  taken  in  every  single 
case.1 

Considering  that  the  object  of  marriage  is  not  the  procreation 
of  descendants  of  any  kind  but  of  vital  descendants  who  shall 
in  their  turn  be  capable  of  propagating  the  race,  the  artificial 
determination  of  pregnancy  has  also  been  recommended  in  cases 
where  on  account  of  the  physical  or  mental  suffering  of  the  preg- 
nant woman  it  is  reasonable  to  expect  sickly  and  inferior  chil- 
dren. It  is  certainly  true  that  the  prevention  of  an  inferior 
progeny  being  brought  into  the  world  would  prove  of  enormous 
benefit  to  the  national  welfare  but  one  would  rather  look  for 
the  realisation  of  this  ideal  in  a  restriction  of  marriages  than  in 
artificial  abortion.  As  long  as  our  moral  and  religious  views  do 
not  permit  an  interference  on  the  part  of  the  State  with  the 
personal  right  of  everyone  to  choose  husband  or  wife,  artificial 
abortion  on  account  of  the  presumably  poor  quality  of  the  foetus 
in  utero  is  absolutely  out  of  the  question. 

As  regards  the  hygiene  of  the  mind  it  is  principally  the 
husband  who  must  attend  to  it.  Good-natured  passive  resistance 
in  the  presence  of  outbreaks  of  ill-temper  on  the  part  of  the 
pregnant  wife;  reasonable  personal  attention  to  the  wants  of 
the  household  and  family  where  everything  suffers  in  conse- 
quence of  ill-management;  avoidance  of  all  psychical  irritation 
and  mental  overexertion  through  quarrels,  exciting  literature, 
heated  discussion,  theatre-going,  concerts,  big  parties  (especially 
at  the  pregnant  woman's  house),  irregular  meals  and  late  hours 
— all  these  points  are  of  the  greatest  importance.  In  the  case 
of  melancholic  depression  the  best  remedy  is  for  the  husband 
to  express  heartily  and  frequently  his  joy  at  the  approaching 
increase  in  the  family  and  his  gratitude  to  the  future  mother. 
The  knowledge  that  the  endurance  of  the  unavoidable  draw- 
backs of  pregnancy  is  a  necessary  accompaniment  of  an  impor- 
tant duty  and  that  it  is  being  rewarded  with  love  and  thankful- 


'Translator's  note.  The  general  practice  in  England  in  such  cases  is  to 
have  a  consultation  with  another  medical  man  before  arriving  at  a  definite 
decision. 


CHILD-BED  257 

ness,  acts  beneficially  even  in  the  case  of  women  in  whom  an 
hereditary  predisposition  or  complicating  diseases  are  the  cause 
of  the  psychical  disturbance.  It  is  also  worth  remembering  that 
in  some  women  melancholia  arises  from  a  feeling  of  shame  at 
the  ungainly  physical  alteration  in  the  figure  and  that  an  aggra- 
vation will  naurally  be  caused  by  any  apparent  neglect  on  the 
part  of  the  husband.  In  such  cases  the  latter  must  continue  to 
observe  most  carefully  the  former  relations  and  affect  a  certain 
tender  and  chivalrous  conduct  towards  the  pregnant  wife.  As 
to  the  utility  or  injuriousness  of  sexual  intercourse  during  preg- 
nancy opinion  is  not  by  any  means  undivided  but  experience 
seems  to  teach  us  that  it  is  not  necessarily  harmful.  It  must  of 
course  be  abstained  from  where  there  is  a  tendency  to  mis- 
carriages or  in  the  last  days  of  pregnancy,  when  there  is  a  risk 
of  premature  rupture  of  the  membranes.  When  it  is  exercised 
all  violence  must  be  avoided,  and  it  may  also  be  necessary,  espe- 
cially where  the  rotundity  of  the  abdomen  is  well-marked,  to 
choose  some  other  suitable  position,  as  f.  i.  the  lateral  one.  In 
view  of  the  circumstance  that  many  pregnant  married  women 
consider  themselves  slighted  by  their  husbands'  continence,  and 
that  on  the  other  hand,  such  continence  is  frequently  a  cause  of 
marital  infidelity  and  possibly  therefore  also  of  the  introduction 
of  venereal  diseases,  the  practitioner  will  do  well  to  be  very 
guarded  in  ordering  sexual  abstinence  during  pregnancy,  and 
to  restrict  the  injunction  to  such  cases  where  it  is  absolutely 
necessary. 

Child-bed. — We  come  now  to  the  consideration  of  the 
puerperium  which  has  without  question,  if  not  in  regard  to  its 
origin  at  least  in  that  of  its  course,  even  where  the  latter  is 
normal,  the  character  of  disease  in  its  state  of  convalescence. 
As  it  is  a  convalescence  from  a  traumatic  injury  the  same  *^ 
method  of  treatment  applies  in  the  case  of  the  puerperal  woman 
as  in  that  of  recovery  from  any  other  injury  and  it  is  therefore 
not  necessary  to  discuss  the  same  on  this  occasion.  But  we  are 
not  concerned  here  even  with  those  special  measures  indicated 
in  the  case  of  every  puerperal  woman,  whether  married  or  not, 
and  will  only  consider  them  in  so  far  as  they  apply  exclusively 
to  the  married  state. 


258  HEALTH,  DISEASE,  MARRIAGE 

That  a  large  number  of  illegitimate  births  take  place  in  hos- 
pitals, schools  of  midwifery  or  nursing  homes  is  an  undoubted 
fact.  And  if  according  to  present  statistics  the  mortality  in 
German  maternity  institutions  is  as  high  as,  or  even  somewhat 
higher  than,  the  general  mortality  of  puerperal  women,  the  rea- 
son is  that  the  institutions  are  debited  also  with  a  not  inconsider- 
able number  of  deaths  of  married  women  who  are  sent  there  on 
account  of  anticipated  dangerous  complications  during  labour 
or  because  they  are  already  severely  infected  or  injured.  That 
under  similar  circumstances  the  danger  connected  with  the  proc- 
ess of  child-birth  is  at  the  present  day  smaller  in  the  case  of 
pregnant  women  entering  institutions  early  enough  than  it  is  in 
those  whose  confinements  take  place  at  their  own  homes,  can 
hardly  be  open  to  any  serious  doubt.  The  possibility  of  thorough 
asepsis  in  the  case  of  the  former,  the  proper  supervision  of 
midwives  and  attendants,  the  more  complete  selection  of  instru- 
ments and  apparatuses  ready  at  hand,  the  better  accommodation 
and  lighting  arrangements,  and  the  constant  presence  of  prop- 
erly trained  medical  officers — all  these  advantages  tend  to  make 
the  conditions  in  suitable  establishments  vastly  superior. 

Nevertheless  such  establishments  are  only  very  rarely  made 
use  of  by  married  women.  In  the  first  instance  on  account  of 
the  impossibility  to  fix  with  certainty  the  date  of  the  expected 
confinement,  the  pregnant  woman  must  necessarily  enter  the 
institution  many  days  and  perhaps  weeks  before  the  anticipated 
event,  otherwise  she  runs  the  risk  of  being  taken  by  surprise 
while  yet  at  home.  She  must  consequently  spend  there  a  con- 
siderable time  for  no  purpose  especially  if  the  confinement  is 
delayed  by  several  weeks  as  it  often  happens.  Not  only  the 
expense  connected  with  such  an  arrangement,  but  the  long  sepa- 
ration from  home  and  her  duties  while  she  considers  herself  as 
yet  equal  to  fulfil  them  to  a  great  extent  is  doubtless  sufficient 
to  act  as  a  deterrent.  Those  who  cannot  afford  to  pay  for  a 
separate  room  at  some  establishment  do  not  care  to  occupy  a 
bed  in  a  large  ward  containing  perhaps  inmates  who  are  not 
suitable  company  for  respectable  women.  It  so  happens  there- 
fore that  the  considerable  advantages  of  child-birth  and  child- 
bed at  suitable  institutions  are  available  for  married  women  to 


CHILD-BED  259 

a  slight  extent  only.  The  homes  for  parturient  women  founded 
since  1887  in  various  places  and  particularly  those  which,  like 
the  first  home  of  the  kind  erected  in  Mannheim,  are  intended 
absolutely  for  married  women  only  have  introduced  a  great 
change.  They  offer  to  women  in  labour  and  in  the  puerperal 
state  all  the  benefits  mentioned  above,  they  admit  women  in 
poor  circumstances  without  any  payment  and  they  have  only 
the  one  drawback  which  is  not  in  reality  without  its  advantages 
to  the  pregnant  woman  herself  that  they  take  her  away  from 
her  household  which  very  probably  suffers  through  the  absence 
of  its  supervising  head  even  if  she  were  to  direct  it  from  her 
sick-bed.  Where  a  fairly  reliable  substitute  is  available  the 
accouchement  and  puerperium  in  such  an  institution  should  be 
recommended  to  future  mothers  as  preferable  from  every  point 
of  view.  There  are  in  many  places  charitable  societies  whose 
object  is  the  provision  of  such  substitutes  as  f.  i.  in  Berlin  the 
society  "Hauspflege"  (Sub-division  of  the  Berlin  Women's 
Society) .  Unfortunately  however  it  is  only  poor  women  who 
are  thus  looked  after;  considering  how  difficult  it  is  for  well- 
to-do  families  also  to  find  a  reliable  substitute  for  the  house-wife 
it  is  very  necessary  that  similar  societies  be  formed  for  the  pur- 
pose of  recommending  respectable  persons  to  those  able  to  pay 
for  their  services. 

But  even  where  the  puerperal  woman  remains  in  her  own 
home  such  a  reliable  substitute  is  very  desirable  seeing  that — 
and  herein  lies  the  great  difference  between  married  and  unmar- 
ried parturient  women — the  mother  is  always  running  the  risk 
of  re-commencing  her  household  duties  and  her  attendance  on 
the  older  children  to  an  extent  not  commensurate  with  the  state 
of  her  health.  It  is  particularly  the  nervous  system  which 
suffers,  and  it  may  even  lead  to  mental  disorders ;  vexation  and 
annoyance  may  also  result  in  her  leaving  the  bed  too  soon  if 
she  notices  that  her  authority  does  not  go  beyond  the  door  of 
her  sick-room,  and  that  everything  outside  it  is  in  wild 
confusion. 

But  also  where  the  substitute  cannot  replace  the  housewife 
in  her  duties  and  privileges  particular  attention  must  be  paid  to 
the  increased  nervous  and  psychical  irritability  of  the  puerperal 


260  HEALTH,  DISEASE,  MARRIAGE 

woman.  The  husband  must  keep  from  her  as  far  as  possible 
all  the  troubles  and  worries  that  he  encounters. 

Finally  as  regards  sexual  intercourse,  most  races  and  espe- 
cially also  the  religions  of  the  Semitic  nations  consider  a  woman 
during  the  lochial  discharge  just  as  unclean  as  when  she  is 
menstruating,  and  conjugal  connection  at  that  time  is  therefore 
prohibited;  on  the  other  hand  the  Catholic  Church  (Alphonse 
of  Liguori)  permits  it.  Whereas  I  regard  the  prohibition 
during  menstruation  with  somewhat  critical  doubts,  I  consider 
intercourse  during  the  puerperal  state,  which  is  unfortunately 
more  frequent  than  one  would  imagine,  as  absolutely  repre- 
hensible. The  existing  hyperaemia  of  the  genitals  is  thereby 
considerably  increased,  greater  or  smaller  labour-wounds  are 
opened  afresh,  new  injuries  are  easily  caused  owing  to  the 
laxity  of  the  mucous  membranes,  opportunities  are  created  for 
infections  to  make  their  entrance,  the  nervous  system  of  the 
wife  is  violently  disturbed,  and  often  a  feeling  of  disgust  and 
aversion  at  the  husband's  embraces  is  thus  instilled  into  her 
mind. 

Lactation. — In  considering  finally  the  suckling  act  or 
lactation,  we  find  in  it  also  phenomena  which  are  to  a  certain 
extent  characteristic  of  disease.  The  secretion  of  the  breasts 
withdraws  from  the  body  a  considerable  amount  of  nourish- 
ment, and  sometimes  a  part  of  its  reserve  material,  so  that  it 
becomes  less  capable  of  performing  its  functions,  and  even  more 
or  less  cachectic.  It  also  becomes  more  susceptible  to  certain 
diseases,  and  less  resistive  against  pulmonary  phthisis  in  par- 
ticular. Lactation  inhibits  the  functions  of  the  ovaries  and 
makes  thus  a  woman  for  the  time  being  sterile,  and  if  continued 
too  long,  is  often  capable  of  producing  considerable  atrophy 
of  the  uterine  walls.  Painful  tension  in  the  breasts  compels 
frequent  application  of  the  child — about  every  3  hours — or 
relief  by  other  means ;  the  mother  is  thus  tied  to  her  child,  she 
cannot  leave  her  house  for  long  without  it  and  is  thus  incapable 
of  seeking  either  work  or  amusement  outside.  Frequently  a 
permanent  loss  of  beauty  is  also  feared,  and  not  without  reason, 
for  the  tense  virginal  breast  with  its  small  nipples  remains  after 
lactation  flaccid  and  the  nipples  considerably  larger. 


LACTATION  261 

In  the  unmarried  woman  these  disadvantages  are,  at  least 
in  Germany,  amply  compensated  by  the  advantages  which  she 
gains  in  becoming  a  wet-nurse  to  other  mothers'  children.  This 
is  not  the  case  with  married  women ;  but  they  also  derive  great 
advantages  from  lactation ;  there  is  the  saving  of  the  high  wages 
and  of  the  keep  of  a  wet-nurse,  and  where  there  is  no  intention 
to  engage  one,  the  avoidance  of  the  many  more  or  less  serious 
ailments  to  which  infants  are  subject  when  brought  up  on  animal 
milk-mixtures  or  vegetable  substitutes.  An  important  advan- 
tage of  lactation  also  lies  in  the  possibility  to  resume  sexual 
intercourse  while  it  lasts  without  there  being  a  probability  of  a 
speedy  new  pregnancy  supervening.  The  disadvantages,  not  only 
pecuniary  but  also  sanitary,  of  frequently  successive  pregnan- 
cies can  therefore  be  avoided  with  a  fair  degree  of  certainty  if 
the  mother  suckles  her  own  child.  Finally  it  is  worth  mentioning 
that  suckling  causes  contractions  in  the  uterine  muscles  and  that 
it  assists  thus  greatly  in  effecting  a  return  of  this  organ  to  its 
normal  conditions. 

It  follows  from  what  has  been  said  that  lactation  is  one  of 
the  conjugal  duties  which  ought  never  to  be  neglected  for  the 
sake  of  the  retention  of  external  beauty  or  haply  from  consider- 
ations of  amusement.  Only  where  the  health  of  the  mother  or 
child  suffers,  that  is,  where  it  exhausts  the  former  or  does  not 
sufficiently  nourish  the  latter,  lactation  is  to  be  desisted  from. 

But  on  the  other  hand  it  is  a  dereliction  of  conjugal  duties 
to  prolong  lactation  beyond  the  proper  term  to  the  detriment  of 
the  suckling  for  no  other  purpose  than  the  avoidance  of  sub- 
sequent pregnancies.  It  is  generally  about  the  9th  or  loth 
month  in  the  life  of  the  child  that  the  latter  begins  to  require 
more  food  than  is  contained  in  its  mother's  milk.  From  that 
time  onwards  it  should  therefore  be  given  other  nourishment, 
but  its  occasional  application  to  the  breast  in  addition  is  not 
contra-indicated,  provided  there  are  no  conditions  of  ill-health 
present  in  the  mother. 


VIII 


Constitutional  (Metabolic)  Diseases  in 
Relation   to   Marriage 


VIII 


By  Professor  H.  Senator  (Berlin) 

We  call  here  constitutional  or  metabolic  diseases,  a  group 
of  chronic  affections  of  the  entire  organism  which  manifest 
themselves  by  definite  disturbances  in  the  metabolism  or  by 
general  disorders  of  nutrition  in  the  absence  of  any  local  or 
primary  organic  disease.  Where  such  organic  disease  does 
exist,  however,  it  is  clinically  eclipsed  by  the  nutritional  and 
metabolic  disorders  in  question. 

This  group  of  diseases  cannot  be  sharply  defined,  or  sepa- 
rated, particularly  from  the  diseases  of  the  circulating  fluid 
which  supplies  all  parts  of  the  body  with  the  material  serving 
for  their  nutrition  and  acts  as  the  medium  of  interchange 
between  nourishment  and  metabolic  products.  There  are  con- 
sequently certain — primary  or  secondary — diseases  of  the  blood 
in  which  the  process  of  metabolism  and  the  entire  nutrition  of 
the  body  suffer  to  a  very  great  extent,  so  that  one  or  the  other 
of  these  conditions  of  ill-health  may  be  included  in  the  one 
group  just  as  well  as  in  the  other,  if  we  do  not  altogether 
prefer  to  combine  both  these  groups  into  a  single  one. 

On  the  other  hand,  it  is  evident,  that  where  the  whole  organ- 
ism is  affected  all  individual  organs  must  also  be  affected  more 
or  less.  These  organic  troubles  are  in  their  turn  capable  of 
giving  rise  to  such  disturbances  that  the  general  state  of  nutri- 
tion becomes  of  secondary  importance  as  compared  to  the 
clinical  aspect  of  a  particular  form  of  disease  which  may  present 
the  characteristic  features  of  organic  disease  rather  than  those 
of  a  constitutional  affection.  Examples  of  this  sort  we  have  in 
rickets  and  osteomalacia,  diseases  which  are  undoubtedly  based 
upon  a  disordered  nutrition  and  metabolism  but  in  which  the 


266  HEALTH,  DISEASE,  MARRIAGE 

affection  of  the  bones  and  the  troubles  arising  from  it  are  such 
prominent  features  that  there  is  as  much  justification  in  classing 
them  among  the  diseases  of  the  bones  and  organs  of  locomotion 
as  among  those  of  metabolism.  Considering  that  in  their  rela- 
tion to  marriage  it  is  almost  exclusively  the  local  lesions  pro- 
duced by  the  diseased  conditions  of  the  bones  which  come  into 
question,  and  not  the  general  disturbance  in  the  nutrition,  they 
will  be  dealt  with  in  another  chapter  of  this  work — among 
the  diseases  of  the  organs  of  locomotion.  The  same  thing 
applies  to  Graves's  disease,  sclerodermia,  etc.  The  former 
doubtless  presents  changes  in  the  metabolism,  but  it  is  doubtful 
whether  they  are  primary  and  whether  they  constitute  the  whole 
characteristic  combination  of  symptoms.  It  is  the  nervous  ele- 
ment which  plays  the  most  important  part  in  this  combination 
especially  with  regard  to  the  conditions  of  married  life,  and  for 
this  reason  it  seems  more  appropriate  to  include  exophthalmic 
goitre  among  the  nervous  diseases  than  among  the  constitutional 
diseases.  As  to  sclerodermia  the  most  prominent  symptom  of 
which  is  constituted  by  the  appearance  of  the  skin,  it  will  receive 
consideration  among  the  diseases  of  this  organ. 

The  diseases  of  the  blood,  in  a  more  restricted  sense,  that  is 
the  conditions  which  are  characterised  mainly  by  alteration  of 
the  blood  and  by  an  inclination  to  haemorrhages,  will  likewise 
receive  consideration  apart  from  the  diseases  of  metabolism 
proper,  and  be  more  suitably  treated  as  a  special  group. 

We  shall  therefore  devote  attention  in  this  chapter  to  the 
following:  Diabetes  mellitus  with  which  it  is  usual  to  associate 
diabetes  insipidus  although  the  latter  is  most  probably  the 
result  of  a  disturbance  in  the  distribution  of  the  watery  element 
based  on  nervous  influences  rather  than  that  of  intrinsic  changes 
in  the  metabolism.  There  also  belong  to  this  group:  Gout 
(arthritis  urica),  obesity  (adipositas  universalis)  and  Dercum's 
disease  (adipositas  dolorosa),  myxoedema,  acromegaly,  Addi- 
son's  disease,  and  scrofula. 

I.  Diabetes  mellitus. — This  disease  doubtless  deserves 
the  first  place  in  connection  with  the  subject  which  interests 
us  here. 

Before  entering  into  details,  it  is  necessary  to  point  out  that 


CONSTITUTIONAL  DISEASES  267 

although  as  is  well  known,  the  diagnosis  of  diabetes  mellitus 
rests  upon  the  presence  of  sugar  in  the  urine  and  can  be  con- 
firmed by  this  test  only,  it  does  not  by  any  means  follow  that 
every  discharge  of  sugar  (especially  that  of  grape-sugar  in  the 
urine)  must  be  regarded  as  a  sign  of  diabetes.  For  there  are 
various  other  conditions  in  which  sugar  appears  in  the  urine — 
though  only  temporarily — so-called  glycosuria  or  mellituria, 
the  different  forms  of  which  it  is  not  the  object  of  this  chapter 
to  enumerate. 

Glycosuria  in  pregnancy  and  cf>ild*bed.—We  will 
only  mention  here  the  elimination  of  sugar,  not  dependent  on 
diabetes,  which  occurs  during  pregnancy  and  child-bed.  There 
are  two  forms  of  it,  namely : 

1.  Lactosuria,  a  discharge  of  milk-sugar  in  the  urine  which 
makes  its  appearance  as  a  rule  a  few  days  after  labour  and  in 
rare  cases  shortly  before  it.     It  results  from  a  congestion  and 
absorption  of  the  milk-sugar  from  the  mammary  glands,  and  is 
therefore  noticed  particularly  in  strong  individuals  with  insuf- 
ficient elimination  of  milk. 

2.  The  glycosuria  of  pregnancy,  in  which  the  urine  con- 
tains grape-sugar  as   in   diabetes  mellitus,   but  only  in  small 
quantities,  not  exceeding  as  a  rule  more  than  \%.     The  fre- 
quency of  these  glycosurias  is  differently  stated,  and  this  may 
be  accounted  for  either  by  the  circumstance  that  the  methods 
employed  for  quantitative  tests  were  of  unequal  strength  or 
by  the  fact  that  the  pregnant  women  examined  used  different 
forms  of  nourishment.     It  has  been  proved  that  the  tolerance 
of  pregnant  women  for  sugar  and  other  carbo-hydrates,  that 
is  the  limit  up  to  which  these  articles  of  food  are  assimilated 
after  their  introduction  into  the  stomach,  is  often  an  exceedingly 
low  one,  and  it  is  therefore  conceivable  that  the  urine  should 
exhibit  different  conditions  varying  with  the  diet  of  the  persons 
examined  and  with  the  greater  or  smaller  amount  of  carbo- 
hydrates generally,  and  sugar  specially,  consumed  by  them.     It 
is  perhaps  thus  that  we  can  explain  the  widely  diverging  state- 
ments of  Brocard1  on  the  one  hand,  and  H.  Ludwig2  on  the 


1Comptes  rendus  de  la  societe  de  Biol.  1898  I  p.  1077. 
'Wiener  klin.    Woch.    1899  No.  12. 


268  HEALTH,  DISEASE,  MARRIAGE 

other.  The  former  found  among  125  pregnant  women  in  their 
7-9  months  of  pregnancy  that  half  (50%)  of  them  showed 
sugar  in  the  urine,  and  almost  in  every  case  grape-sugar;  the 
latter  detected  fermentable  sugar  in  the  urine,  and  in  most  cases 
only  a  few  times  and  in  insignificant  quantities,  in  no  more  than 
1 8  out  of  8  2  pregnant  women  (22%). 

Neither  the  glycosuria  nor  the  lactosuria  of  pregnant  and 
puerperal  women  cause  any  complaints;  they  are  both  physio- 
logical processes  which  may  at  the  utmost  be  regarded  as 
inclining  to  the  border  of  the  pathological  domain,  but  they 
nevertheless  deserve,  and  the  glycosuria  more  than  the  lacto- 
suria, every  attention  from  the  medical  man,  who  if  he  will  not 
immediately  conclude  the  presence  of  diabetes  will  at  least  have 
reason  to  recommend  caution  for  the  future  to  the  pregnant 
woman  in  question.  Because,  since  this  glycosuria  is  probably 
the  result  of  a  diminished  power  of  assimilating  sugar,  it  might 
occasionally  constitute  the  beginning  of  a  genuine  diabetes,  espe- 
cially if  it  occurs  not  only  after  the  consumption  of  sugar  (as 
"glycosuria  e  saccharo")  but  also  after  that  of  starchy  food 
(as  "glycosuria  ex  amylo"  of  Naunyn)  or  if  there  are  also  other 
factors  present  that  predispose  to  diabetes,  especially,  for 
instance,  an  hereditary  predisposition. 

From  what  has  just  been  said  we  may  draw  the  conclusion 
that  the  medical  man  will  do  well,  even  where  pregnancy  takes 
a  normal  course,  to  periodically  examine  the  urine  for  sugar 
and  to  advise  accordingly. 

Influence  of  marriage  on  diabetes  metlitus. — 
Coming  now  to  diabetes  proper,  we  have  first  to  consider  the 
question,  as  laid  down  in  the  introduction,  whether  this  disease 
can  be  influenced  by  marriage,  and  especially  whether  the  indi- 
vidual suffering  from  it  may  expect  in  consequence  of  his  or 
her  marriage  an  improvement  or  an  aggravation  in  the  disease 
or  a  shortening  in  the  duration  of  his  or  her  life.  In  other 
words:  Are  there  conditions  created  or  altered  by  marriage 
which  have  an  influence  one  way  or  another  upon  the  course  of 
diabetes  ? 

Experience  has  shown  that  the  course  of  diabetes,  apart 
from  complications  and  general  circumstances  of  importance 


CONSTITUTIONAL  DISEASES  269 

in  every  chronic  disease  such  as  nutrition  and  strength,  depends 
in  the  first  instance  upon  its  form.  It  is  well  known  that  there 
are  milder  and  severer  forms  of  diabetes  according  to  the  toler- 
ance for  carbo-hydrates,  although  the  latter  does  not  supply 
an  absolutely  safe  criterion.  The  reason  for  this  lies  chiefly 
in  the  fact  that  it  is  not  possible  to  draw  the  line  between 
the  two  forms  with  respect  to  the  ability  to  assimilate  carbo- 
hydrates, and  also  because  transitions  occur  from  the  milder 
to  the  severer  form  as  do  also  changes  in  the  condition  of  the 
same  patient.  It  is  of  importance  to  remember  that  it  is  very 
frequently  possible  by  suitable  treatment  and  especially  by  a 
correct  diet  to  increase  the  tolerance  for  carbo-hydrates  and 
thus  to  ameliorate  the  course  of  the  disease.  Such  treatment 
and  the  hygienic  life  connected  with  it  are  however  very  expen- 
sive considering  that  they  must  be  resumed  or  modified  period- 
ically and  repeatedly,  and  they  can  only  be  indulged  in  success- 
fully where  there  is  a  certain  amount  of  affluence  and  independ- 
ence in  the  struggle  for  existence. 

Age  is  also  a  very  important  factor.  Generally  speaking, 
the  course  of  diabetes  in  the  earlier  years,  to  about  the  middle  of 
the  third  decade,  is  more  rapid  and  more  unfavourable  than  at  a 
more  advanced  age. 

Psychical  influences,  especially  those  of  a  depressing  char- 
acter such  as  fright,  sorrow,  etc.  act  aggravatingly  on  the 
disease  and  may  even,  where  there  is  a  predisposition  to  it,  f.  i. 
heredity,  often  form  the  occasion  of  its  origin. 

Pregnancy  and  labour  have  also  occasionally  given  rise  to 
diabetes  or  caused  it  to  become  manifest  for  the  first  time. 
More  frequently  these  processes  lead  to  an  aggravation  of  an 
existing  diabetes  inasmuch  as  a  milder  form  passes  into  a  severer 
one  owing  to  a  diminution  in  the  tolerance  for  carbo-hy- 
drates, or  a  rapidly  running  pulmonary  tuberculosis  supervenes 
which  ends  as  a  rule  fatally  shortly  after  labour.  In  other 
cases,  death  occurs  during  child-bed  from  coma  or  sudden 
collapse. 

As  to  how  often  these  processes  exert  their  fatal  influence, 
with  what  degree  of  probability  the  latter  may  therefore  be 
expected,  it  is  impossible  to  say,  as  the  number  of  recorded 


270  HEALTH,  DISEASE,  MARRIAGE 

observations  bearing  on  the  point  is  far  too  small  to  permit 
even  an  approximate  estimate  only.1 

The  influence  of  lactation  on  the  course  of  diabetes  has 
received  even  less  attention  from  observers.  But  with  regard 
to  it  we  may  also  take  it  for  granted  that  it  has  the  effect  of 
aggravating  the  disease,  and  that  where  there  is  a  complicating 
pulmonary  tuberculosis,  there  may  arise  the  greatest  danger  to 
life. 

From  the  above  remarks  we  may  infer  that  marriage  pre- 
sents as  a  rule  no  particular  risk  to  a  man  suffering  from  diabetes, 
seeing  that  most  men  are  not  too  young  when  entering  the  mar- 
ried state,  and  that  a  rapid  course  of  the  disease  is  consequently 
not  to  be  feared.  But  such  a  contingency  might  nevertheless 
happen,  when  the  external  circumstances  are  so  unfavourable 
that  the  necessary  or  desirable  mode  of  life  cannot  be  instituted 
or  where  intense  psychical  emotions  are  produced  by  pecuniary 
troubles  or  other  circumstances  which  tend  to  mar  the  happiness 
of  married  life. 

Where  there  are  such  unfavourable  circumstances  attending 
a  marriage  about  to  be  entered  into,  or  where  there  is  reasonable 
ground  for  assuming  that  they  will  subsequently  arise,  the  med- 
ical man's  duty  is,  if  consulted  on  the  point,  to  dissuade  diabetic 
men  from  marrying ;  he  will  do  well  to  offer  the  same  advice  in 
cases  where  the  patients  are  rather  young,  or  to  insist  at  least 
that  the  marriage  be  postponed  till  the  3Oth  year  has  been 
passed,  and  the  longer  the  postponement  the  better. 

Where  the  unfavourable  circumstances  are  not  present, 
there  is  no  fear  that  marriage  will  endanger  the  life  or  health  of 
a  man  suffering  from  a  mild  form  of  diabetes,  and  in  so  far 
as  these  questions  are  concerned  there  is  no  indication  to 
oppose  the  marriage. 

On  the  other  hand,  a  patient  suffering  from  a  severe  form 
of  the  disease  must  under  no  circumstances  be  recommended  to 
marry,  because,  even  if  his  condition  is  not  likely  to  be  aggra- 
vated by  the  marriage,  he  has  very  little  prospect  of  reaching 
the  natural  life-limit.  To  obtain  an  approximate  idea  as  to  the 


'For  opinions  on  the  subject  see  O.  O.  Fellner,  Die  Beziehungen  innerer 
Krankheiten  zur  Schwangerschaft,  1903,  p.  229. 


CONSTITUTIONAL  DISEASES  271 

seriousness  of  a  case  one  may,  apart  from  other  considerations, 
study  the  tolerance  for  carbo-hydrates.  The  patient  who  can- 
not, on  an  empty  stomach,  consume  at  least  100-150  grammes 
of  white  bread  or  120-200  grammes  of  brown  bread  (60-90 
grammes  of  carbo-hydrates)  without  showing  sugar  in  the  urine 
in  the  next  6  hours,  must  be  considered  as  suffering  from  a 
severer  form. 

The  conditions  are  different  and  more  unfavourable  in  the 
diabetes  of  females.  In  the  first  instance  girls  marry  as  a  rule 
at  an  earlier  age  than  men,  that  is  at  a  time  of  life  when 
diabetes  is  less  benign  in  its  course,  so  that  the  probable  duration 
of  life  is  to  begin  with  shortened.  For  this  reason,  I  think  it 
justifiable  in  view  of  the  dangers  threatened,  to  advise  young 
girls  suffering  from  diabetes  not  to  marry.  Women  of  more 
advanced  age  affected  with  the  disease  in  a  mild  form  should 
be  told  what  dangers  they  are  incurring  by  marrying,  and  the 
medical  man  should  even  where  the  circumstances  are  otherwise 
favourable  give  his  consent  to  the  marriage  only  with  a  certain 
amount  of  reservation. 

Transmissibility  of  diabetes  in  married  life. — 
A  further  question  is  whether  husband  or  wife  runs  any  special 
risk  through  the  diabetes  of  the  other  partner,  that  is,  not  only 
in  so  far  as  a  chronic  disease  accompanied  by  painful  or  danger- 
ous symptoms  is  likely  to  cause  suffering  and  inconvenience  to 
persons  living  in  close  intimacy  with  the  patient,  but  in  a  specific 
manner.  In  other  words,  can  diabetes  be  transmittted  from 
husband  to  wife  or  vice  versa?  It  is  some  time  now  since  it 
has  been  pointed  out  by  various  observers  that  diabetes  occurs 
in  married  couples,  especially  by  K.  Schmitz1  who  found  among 
2,320  diabetics  seen  by  him  26  married  couples  (1.1%).  The 
same  proportion,  namely  10  married  couples  among  900  dia- 
betics, was  found  by  B.  Oppler  and  E.  Kiilz2  who  calculated 
at  the  same  time  that  1,169  cases  of  diabetes  reported  by  other 
authors  included  1 1  married  couples,  or  a  proportion  only 
slightly  smaller  (0.9%).  I  have  also  reported  770  cases  of 


TJerl.  klin.  Woch.,  1890,  No.  20. 

*Berl.  klin.  Woch.,  1896,  Nos.  26  and  27. 


272  HEALTH,  DISEASE,  MARRIAGE 

diabetes  with  9  married  couples  (l.ig%).1  But  as  my  material 
on  that  occasion  consisted  of  private  patients  as  well  as  of  hos- 
pital in-and-out-patients,  whereas  the  other  statistics  mentioned 
included  probably  patients  belonging  to  the  better  classes  only 
(such  as  are  in  the  habit  of  frequenting  the  various  watering- 
places)  I  have  now,  so  as  to  make  comparison  easier,  compiled 
a  new  list  of  my  private  patients  only,  and  the  latter  shows  that 
892  diabetics  include  at  least  15  married  couples  (1.6%). 
This  proportion  though  somewhat  higher  than  the  other 
figures  given  above  is  still  so  small  that  it  does  not  seem  sufficient 
to  support  the  view  that  diabetes  is  contagious. 

But  H.  Leo2  has  protested  against  this  method  of  calcula- 
tion which  takes  into  account  married  and  unmarried  diabetics 
together,  and  he  is  right  in  demanding  that  for  purposes  of 
establishing  the  contagiousness  of  diabetes  the  proportionate 
frequency  should  be  reckoned  among  married  diabetics  only  and 
it  would  then  of  a  necessity  appear  much  higher.3 

In  addition,  there  is  a  number  of  observations,  not  very 
great  but  yet  sufficient  to  attract  attention,  of  the  presence  of 
diabetes  among  persons  not  related  by  blood  and  not  married 
to  one  another,  under  circumstances  which  suggest  the  possi- 
bility of  contagion. 

Thus  Teissier  (Lyon)  quoted  by  Oppler  and  Kiilz, 
reports  the  case  of  a  laundress  62  years  old  formerly 
in  good  health,  (as  was  also  her  husband  and  6  chil- 
dren), who  contracted  diabetes  after  having  washed  for 
6  months  the  linen  of  a  severe  diabetic  and  that  of  his 
granddaughter  who  was  also  suffering  from  diabetes. 
More  decisive  still  is  his  following  observation:  A 
gouty  man  whose  mother  had  died  from  diabetes  devel- 
oped glycosuria  in  consequence  of  intense  worry.  After 
6  months  his  cook  aged  60,  who  had  hitherto  been  in 
perfect  health,  fell  ill  with  diabetes ;  she  had  been  in  the 
habit  of  washing  her  master's  handkerchiefs.  A  sew- 


'Berl.  klin.  Woch.,  No.  30. 

*Uber  Wesen  und  Ursache  d.  Zuckerkr.  Berlin,  1900,  p.  86. 
'I  am  sorry  to  say  I  have  not  thought  of  this  point  before,  and  I  do  not 
know  with  regard  to  many  male  diabetics  whether  they  were  married. 


CONSTITUTIONAL  DISEASES  273 

ing-woman,  50  years  old,  who  had  been  employed  in  the 
house  for  10  years  and  who  assisted  the  cook,  also  sick- 
ened one  year  after  her  master  became  ill  and  exhibited 
intermittent  glycosuria. 

Teissier  mentions  also  briefly  the  case  of  a  coach- 
man who  used  to  wait  at  table  and  in  whom  diabetes 
was  diagnosed  shortly  after  his  master  became  slightly 
diabetic  as  the  result  of  an  attack  of  anthrax  in  the  face. 
Also,  the  case  of  a  restaurant-proprietor  who  used  to 
take  his  meals  with  his  diabetic  sister-in-law  and  who 
became  diabetic  after  6  months. 

E.  Kiilz1  noticed  diabetes  in  5  inmates  of  the  same 
house. 

Naunyn2  saw  3  cases  of  diabetes  in  people  who  lived 
under  the  same  roof  with  some  diabetics  who  were  not 
related  to  them.  Among  them  was  the  case  of  a  young 
woman  who  developed  a  fairly  severe — and  probably 
temporary? — glycosuria  after  having  stayed  a  few 
weeks  with  a  diabetic  non-consanguineous  aunt  whose 
husband  was  also  diabetic.  But  the  diabetes  of  both 
hosts  was  very  mild  in  form,  and  both  were  almost 
entirely,  or  nearly  so,  free  from  sugar. 

I  have  also  seen  a  few  cases  of  diabetes  in  persons 
who  were  not  hereditarily  predisposed  and  related,  not 
consanguineously,  but  by  marriage,  to  diabetics  with 
whom  they  came  in  close  contact,  thus,  f.  i.  in  the  wife 
of  a  man  whose  brother  as  also  the  latter's  wife  were 
diabetics. 

More  remarkable  however  than  all  these  observa- 
tions is  the  following:  Dr.  H.  42  years  old,  medical 
practitioner  in  a  small  provincial  town  with  about  2,500 
inhabitants,  hitherto  in  good  health  and  not  hereditarily 
predisposed,  consulted  me  in  March,  1 899,  on  account  of 
his  diabetes  which  he  had  noticed  shortly  after  having 
amputated  a  gangrenous  thigh  in  a  diabetic  patient. 


lin.  Erfahrungen  iiber  Diabetes  mellitus.  Edited  by  Rumpf,  etc.    Jena, 
1899,  p.  246. 

'Nothnagel's  Spec.  Path.  VII.,  p.  126. 


274  HEALTH,  DISEASE,  MARRIAGE 

At  the  same  time  there  were  in  one  single  street  of  the 
little  town  5  more  diabetics,  namely  4  men  of  whom  one 
was  the  proprietor  of  an  inn — which  the  other  three 
frequently  visited,  and  a  woman,  the  wife  of  one  of 
these  3  diabetic  men. 

None  of  these  observations,  however,  supply  an  incontro- 
vertible proof  of  the  contagiousness  of  diabetes.  The  striking 
coincidence  in  these  cases  might  be  explained  without  the  inter- 
vention of  a  contagious  element  by  assuming  that  the  presence 
of  the  disease,  or  the  occurrence  of  grave  symptoms  in  one 
person  causes  another  who  has  relations  with  him  to  direct  his 
attention  to  the  state  of  his  own  urine  and  thereby  to  discover 
a  diabetes  which  was  already  existing  previously  though  perhaps 
in  a  latent  form  only.  Or  there  may  possibly  be  in  the  case  of 
one  or  another  of  these  apparently  infected  diabetics  an  heredi- 
tary predisposition  if  not  to  diabetes,  perhaps,  to  some  other 
disease  etiologically  connected  with  it,  such  as  gout,  obesity,  or 
psychosis,  and  some  circumstance  arising  from  the  intercourse 
with  the  diabetic,  as  f.  i.  mental  shock  at  the  occurrence  of  coma 
or  gangrene,  etc.  constituted  an  opportunity  for  the  disease  to 
break  out.  Finally,  one  might  find  the  explanation,  as  I  pointed 
out  long  since1  with  regard  to  the  then  hardly  known  occurrence 
of  diabetes  in  married  couples,  in  the  circumstance  that,  if  not 
an  absolute  coincidence,  the  same  causative  conditions  produce 
the  same  effect  in  the  husband  and  the  wife, — an  explanation 
which  received  fairly  universal  assent. 

But  these  explanations  are  after  all  nothing  but  conjectures 
of  which  the  one  may  have  more  and  the  other  less  in  its  favour 
than  the  theory  of  contagiousness.  Some  of  the  cases  quoted, 
and  particularly  the  last,  are  so  remarkable  that  they  give  food 
for  reflection  whether  some  cases  of  diabetes  are  not  in  reality 
due  to  contagion.  The  attempts  to  examine  this  point  experi- 
mentally have  shown  that  it  is  not  entirely  without  some  justi- 
fication, but  so  far  they  have  not  led  to  any  definite  conclusions. 
We  must  therefore  at  all  events  reckon  with  the  remote 
possibility  that  where  either  husband  or  wife  suffers  from  dia- 

1H.  Senator,  Diabetes  in  v.  Ziemssen's  Spec.-Pathol.  XIII.  2,  1876,  p.  122 
and  2nd  edit.  1879,  p.  394. 


CONSTITUTIONAL  DISEASES  275 

betes  the  other  partner  may  sooner  or  later  also  develop  the 
disease.  But  the  degree  of  probability  of  this  contingency  is 
according  to  our  present  experience  a  very  small  one,  somewhat 
greater  perhaps  where  the  individual  as  yet  free  from  the 
disease  is  hereditarily  predisposed  to  it,  but  for  all  that  not 
sufficiently  great  to  justify  the  medical  man  in  taking  special 
precautions  which  entail  more  than  a  correct  hygienic  and 
dietetic  mode  of  life. 

Influence  on  the  generative  faculty. — In  other  ways, 
too,  diabetes  may  have,  owing  to  certain  of  its  peculiarities,  an 
effect  upon  the  course  of  marriage.  Firstly,  as  regards  the 
husband,  there  may  be  sexual  impotence,  a  very  frequent  symp- 
tom, which  appears  sometimes  early  even  in  mild  forms  of  the 
disease  and  sometimes  later  in  its  course,  and  which  can  often 
be  removed  permanently  or  temporarily  by  suitable  treatment. 
Secondly,  as  regards  the  wife:  Besides  amenorrhoea  and  other 
disturbances  of  menstruation  which  are  as  far  as  married  life 
is  concerned  of  no  practical  importance,  sterility  is  frequently 
seen  in  diabetic  women  as  a  consequence  of  various  causes,  f.  i. 
atrophy  of  the  uterus  or  of  the  ovaries,  prevention  of  conception 
through  the  abnormal  constitution  of  the  vaginal  secretion, 
inflammation  and  ulceration  of  the  vulva  and  vagina,  etc. 
Where  conception  does  take  place,  which  is  frequently  the  case, 
the  pregnancy  is  in  a  considerable  number  of  cases  interrupted 
prematurely,  either  spontaneously  or  by  medical  interference. 

And  now,  in  order  to  save  the  diabetic  wife  from  the 
dangers  of  pregnancy  and  labour,  the  question  arises  as  to 
whether  conception  shall  be  prevented.  But  this  is  a  measure 
which  is  connected  with  so  many  different  circumstances,  includ- 
ing some  which  do  not  even  belong  to  the  domain  of  the 
physician,  that  the  latter  will  be  well  advised  on  occasions  of 
this  kind  to  leave  the  decision  to  the  respective  married  couples 
themselves. 

Opinion  is,  however,  divided  as  to  whether  it  is  advisable, 
where  pregnancy  has  occurred,  to  interrupt  the  same  by  the 
induction  of  abortion  or  premature  labour,  and  it  is  hardly 
possible  here,  like  in  many  other  diseased  conditions  to  lay 
down  any  general  rules  for  the  guidance  of  all  pregnant  women. 


276  HEALTH,  DISEASE,  MARRIAGE 

For,  as  already  stated,  on  the  one  hand  the  foetus  often  dies  and 
is  expelled,  making  interference  unnecessary,  and  on  the  other 
the  life  of  the  mother  is  more  and  more  in  jeopardy  as  the 
pregnancy  advances  and  labour  approaches.  The  physician 
will  therefore  have  to  take  into  consideration  in  each  individual 
case,  above  everything  else,  the  severity  of  the  disease  and 
the  state  of  nutrition  and  strength  of  the  mother. 

The  premature  interruption  of  the  pregnancy  by  the  induc- 
tion of  abortion  is  generally  considered  to  present  the  best 
chances  for  the  mother.  It  is  however  necessary  to  ascertain 
first  what  value  is  attached  by  the  married  couple  or  by  those 
who  represent  them  to  the  advent  of  the  child,  as  circumstances 
might  necessitate  the  preservation  of  its  life,  though  perhaps 
at  the  cost  of  that  of  the  mother.  It  is  therefore  advisable  in 
order  to  guard  against  future  reproaches  to  leave  the  decision 
entirely  in  the  hands  of  the  relatives  after  having  explained 
to  them  the  probabilities  of  the  case.  A  safe  rule  in  such  cases 
is  to  call  in  a  second  medical  man  to  share  the  responsibility. 

Influence  on  the  offspring. — Diabetes  presents  finally 
a  double  danger  to  the  offspring.  First,  because  the  children 
of  diabetic  mothers,  though  they  are  often  born  alive,  come 
into  the  world  in  a  weak  and  pitiful  condition,  and  secondly  on 
account  of  the  hereditary  character  of  the  disease.  For  of  all 
etiological  factors  heredity  is  the  one  which  is  most  frequently 
and  most  surely  demonstrable.  Older  authors  knew  already 
of  the  occurrence  of  diabetes  in  several  members  of  the  same 
family  or  in  several  generations,  and  recently,  since  the  subject 
has  received  attention  not  only  with  regard  to  the  presence  of 
the  disease  in  parents  or  in  brothers  and  sisters,  but  also  in  more 
distant  blood-relations,  the  number  of  cases  observed  has  grown 
more  and  more.  More  than  40  years  ago,  when  diabetes  was 
still  regarded  as  a  fairly  rare  disease  Griesinger  was  able  to 
prove  heredity  in  3  cases  only  out  of  225  observations  collected 
by  him  (1.3%)  ;  but  Frerichs  established  hereditary  predispo- 
sition in  10%  of  his  cases,  Gruber  in  8%,  Teschenmacher  in 
fully  8%,  See  gen  in  14%  and  Bouchard  in  as  many  as  25%. 
More  recent  calculations  depending  on  material  somewhat  sim- 
ilar to  each  other,  that  is,  with  exclusion  of  hospital  in-and-out- 


CONSTITUTIONAL  DISEASES  277 

patients,  do  not  reveal  such  diverging  percentages.  The  figures 
of  von  Noorden  show  hereditary  predisposition  in  18.5%,  those 
of  Kulz  21.6%  (150  times  out  of  692  cases),  those  of  Naunyn 
17.4%  (35  times  out  of  201  cases),  and  my  own  records  show 
decided  hereditary  or  familiar  predisposition  in  iS.6%  (166 
times  out  of  892  diabetics) .  A  far  higher  percentage  was  found 
only  by  R.  Schmitz1  in  Neuenahr,  who  established  hereditary 
predisposition  in  998  out  of  2115  diabetics  (47%). 

Even  if  we  leave  the  last  figure  out  of  account,  the  propor- 
tion is  still  high  enough  to  deserve  serious  consideration.  A 
fifth  of  all  diabetics  who  are  seen  in  private  practice  and  are 
presumably  part  of  the  better-class  population  is,  at  least  as 
regards  Germany,  most  certainly  hereditarily  predisposed  to 
diabetes.  But  the  proportion  among  the  poorer  patients  who 
are  seen  in  hospital  practice  also  seems  to  be  about  the  same. 
For  various  and  obvious  reasons,  the  family  histories  given  by 
this  class  of  patients  with  reference  to  diseases  in  their  parents, 
brothers,  sisters  or  more  distant  relations  are  not  very  reliable; 
I  have  nevertheless  been  able  to  ascertain  hereditary  or  familiar 
predisposition  in  14-17%  out  of  79  cases  seen  at  the  Berlin 
University  Polyclinic  which  disclosed  any  etiological  informa- 
tion.2 

That  diabetes,  resting  on  hereditary  predisposition  fre- 
quently passes  over  one  generation  and  appears  in  the  third,  is 
well  known.  But  what  has  struck  me  is  that  in  such  cases 
the  disease  often  makes  its  appearance  at  an  early  age,  and  even 
in  very  young  children.  Among  25  diabetic  children  between 
3  and  18  years  old,  whom  I  saw  in  consulting  practice,  and 
13  of  whom  were  boys  and  12  girls,  there  were  7  whose  parents 
were  free  from  the  disease,  while  one  of  their  grandparents  had 
suffered  from  diabetes.  As  usual  in  such  young  persons,  the 
disease  took  in  all  of  them  a  very  rapid  course,  and  in  one  case 
death  occurred  within  1 1  or  12  days. 

With  regard  to  the  question  of  marriage  and  attitude  during 
married  life,  there  are  no  doubt  diabetics  who  are  not  altogether 


'fieri,  klin.  Woch.  1891,  No.  27. 

2Compare    G.    Jablotschkoff,    Statist.    Beitrage   zur   Aetiologie   d.    Diab. 
mell.  und  insipid.  Dissert.,  Berlin,  1901. 


278  HEALTH,  DISEASE,  MARRIAGE 

indifferent  about  the  possibility  of  the  disease  being  transmitted 
to  their  descendants,  but  generally  speaking  not  much  impor- 
tance is  attached  to  the  point,  seeing  that  the  contingency  is  one 
to  be  relegated  to  the  more  or  less  distant  future.  The  physi- 
cian should  however,  without  pretending  to  prophesy,  express 
an  opinion  in  that  direction  if  consulted  at  all  in  the  matter,  and 
endeavour  if  it  lies  in  his  power  to  avert  possible  mischief. 
The  precautions  which  might  eventually  become  necessary  in 
view  of  the  hereditary  transmission  of  diabetes  are  practically 
the  same  as  those  indicated  when  the  question  of  marriage  arises 
or  as  those  to  be  adopted  during  the  married  state. 

If  a  viable  child  is  born  to  a  diabetic  father  or  a  diabetic 
mother,  it  is  the  duty  of  the  medical  attendant  to  watch  it  most 
carefully,  and  to  examine  the  urine  as  often  as  possible,  so  that 
in  case  any  symptoms  of  diabetes  should  make  their  appearance, 
he  could  at  once  institute  the  necessary  treatment  and  endeavour 
to  counteract  the  disease,  if  possible.  Unfortunately,  he  will 
achieve  this  the  more  rarely,  the  younger  the  child. 

On  the  strength  of  what  has  been  said  above,  the  attitude 
of  the  medical  man  on  the  question  of  the  marriage  and  married 
life  of  diabetic  individuals  may  be  summarised  as  follows: 

A  person  suffering  from  diabetes  should  be  advised  not 
to  marry  before  the  age  of  30-35. 

In  a  man  who  has  reached  or  exceeded  this  age  the  con- 
ditions which  render  marriage  undesirable  are :  a  grave  form  of 
the  diabetes,  permanent  impotency  and  unfavourable  external 
circumstances  such  as  are  likely  not  to  be  improved  or  to 
become  even  worse  by  marriage.  Where  these  conditions  do 
not  exist,  the  man  must  not  exactly  be  advised  to  marry,  but 
neither  must  he  be  dissuaded  from  doing  so.  It  is,  however, 
necessary  to  inform  him  of  the  dangers  which  may  accrue  to 
his  eventual  offspring. 

Diabetic  females  who  have  either  reached  or  passed  the 
above-mentioned  age  should,  where  the  disease  is  of  a  severe 
type,  or  where  the  outward  circumstances  are  unfavourable,  be 
distinctly  dissuaded  from  marrying.  Otherwise,  and  where  the 
person  concerned  is  still  of  a  conceivable  age,  the  doctor  must 
not  recommend  marriage,  but  after  having  pointed  out  the 


CONSTITUTIONAL  DISEASES  279 

dangers  arising  to  herself  from  an  eventual  pregnancy,  and 
those  threatening  her  eventual  offspring,  he  should  leave  the 
decision  to  her. 

The  decision  as  to  whether  married  couples  should,  on 
account  of  the  dangers  mentioned  above,  prevent  conception 
must  be  left  to  them  entirely. 

Where  pregnancy  supervenes  the  question  whether  the  same 
should  be  arrested  deserves  to  be  taken  into  consideration,  and 
measures  will  be  taken  in  accordance  with  the  views  expressed 
above  preferably  in  conjunction  with  a  second  medical  man.  It 
is  advisable  to  examine  periodically  for  sugar  the  urine  of  every 
pregnant  woman  especially  where  there  is  an  hereditary  pre- 
disposition to  diabetes. 

Diabetic  women  should  on  no  account  be  allowed  to  suckle 
their  children. 

Finally,  it  is  self-evident  that  the  diabetes  of  husband  or 
wife  must  in  every  case  be  medically  treated,  and  that  those 
symptoms  especially,  which  act  injuriously  upon  the  married 
state,  must  also  receive  most  careful  attention. 

II.  Diabetes  insipidus  (polyuria). — This  disease  is 
not  frequent,  it  seldom  endangers  life,  and  it  is  generally  accom- 
panied more  by  inconvenient  disturbances  than  by  grave  symp- 
toms.    For  this  reason  it  does  not  present  any  special  points  in 
reference  to  the  question  of  marriage  and  of  the  married  state, 
and  no  other  significance   than   that  of  a   minor  ailment  of 
indefinite  duration.     The  only  element  which  might  come  into 
consideration  from  our  present  point  of  view  is  that  of  heredity; 
but  such  an  heredity  has  not  on  the  whole  been  often  observed; 
far  more  rarely  than  in  diabetes  mellitus,  and  in  contrast  to  the 
latter,  the  hereditary  form  of  polyuria  does  not  present  any 
special  dangers  with  regard  to  the  duration  of  life.     There 
are  on  the  contrary  examples  that  members  of  families  affected 
with  the  disease  have  exhibited  as  a  rule  remarkable  longevity.1 
From  this  standpoint  neither,  does  polyuria  therefore  present 
any  special  misgivings. 

III.  Arthritis     urica    (gout).—  It    is    necessary    to 


1A.  Weil,  Virchow's  Arch.,  1884,  Vol.  95. 


280  HEALTH,  DISEASE,  MARRIAGE 

remark  at  the  outset,  that  we  are  considering  here  only  the 
so-called  real  gout,  (arthritis  urica  or  vera)  and  not  the  allied 
painful  affections  of  joints  or  neighbouring  tendons  and  bones, 
which  are  often  designated  by  the  public  as  "gout." 

Heredity. — The  importance  of  this  genuine  gout  from  the 
point  of  view  of  marriage  lies  almost  exclusively  in  its  etiolog- 
ical  conditions,  and  especially  in  the  circumstance  that  it  rests 
upon  heredity  more  than  perhaps  any  other  disease.  This  fact, 
which  was  already  known  to  former  generations  of  medical 
men,  has  been  confirmed  again  and  again,  although  the  figures 
at  our  disposal  relating  to  the  frequency  with  which  gout  is 
demonstrable  among  blood  relations  do  not  agree  with  each 
other,  a  circumstance  which  is  hardly  surprising  seeing  how 
difficult  it  is  to  obtain  reliable  family  histories.  The  proportion 
varies  perhaps  in  different  countries  under  the  influence  of 
climate,  race,  etc.  It  is  certain  that  even  if  we  reckon  the  direct 
transmission  of  the  disease  from  parents  or  grand-parents  only, 
heredity  is  demonstrable  in  almost  60%  of  the  cases,  and  the 
percentage  is  naturally  greater  if  we  take  into  consideration 
collateral  lines  as  well.  This  applies  at  least  to  England,  the 
classical  home  of  gout.1  In  Germany  the  proportion  does  not 
seem  to  be  any  smaller,  if  it  is  not  larger,  as  Braun2  says  that 
among  65  gouty  patients  he  did  not  find  a  single  one  who  was 
not  hereditarily  predisposed.  In  France  the  proportion  appears 
to  be  somewhat  less;  it  is  according  to  Lecorche3  $7%,  and 
according  to  Patissier*  and  Bouchard5  only  about  43-44%.  Like 
other  hereditary  diseases,  gout  also  shows  occasionally  omissions 
in  intervening  generations. 

There  is,  besides,  a  correlation  resting  on  an  hereditary  basis 
between  gout  and  diabetes,  of  such  a  kind  that  the  former  pre- 
disposes as  a  rule  to  the  latter;  very  seldom  it  is  the  other  way. 
Hence  why  we  oftener  see  diabetes  appearing  in  gouty  families 


*Ch.  S.  Scudamore,  A  treatise  on  the  nature  and  cure  of  gout,  etc. — 
'A.  B.  Garrod,  The  nature  of  treatment  of  gout. 

'Beitrage  zu  einer  Monographic  der  Gicht,  Wiesbaden,   1860. 

Traite  de  la  goutte.    Paris,  1884. 

'Bull,  de  1'acad.  de  Med.,  1840. 

'Maladies  par  ralentissement  de  la  nutrition. 


CONSTITUTIONAL  DISEASES  281 

or  gouty  individuals  contracting  diabetes  in  addition,  than  gout 
added  to  diabetes.  It  is  worth  mentioning  that  diabetes  super- 
vening on  gout  generally  runs  a  favourable  course. 

Other  etiological  conditions. — The  hereditary  trans- 
mission of  gout  occurs  more  frequently  from  the  father's  side 
than  from  the  mother's,  and  this  is  probably  easily  explained 
by  the  enormously  greater  frequency  of  the  disease  in  the  male 
sex.  The  exact  proportion  of  this  greater  frequency  is  difficult 
to  ascertain,  because  the  statements  on  the  subject  vary  so  much, 
and  this  in  its  turn  is  due  to  the  circumstance  that  different 
observers  take  different  views  of  what  arthritis  or  "gout"  is. 
In  women  especially,  it  is  a  common  thing  to  include  among 
cases  of  real  gout  other  forms  of  chronic  articular  inflammation, 
such  as  arthritis  deformans.  Gout  is,  according  to  general 
experience,  principally  a  disease  of  advanced  age;  only  excep- 
tionally the  disease  has  been  observed  in  individuals  under 
25  years  of  age,  or  in  children,  but  it  appears  that  such  cases 
may  occur,  especially  in  families  severely  predisposed  to  gout 
through  a  series  of  several  generations. 

The  occurrence  of  gout  is  facilitated  by  an  intemperate  and 
over-indulgent  mode  of  «life  accompanied  by  an  excess  of  food 
and  meat  in  particular,  abuse  of  alcoholic  liquors  especially 
certain  heavy  kinds  of  wine  and  beer,  insufficient  physical 
exercise  and  sexual  transgressions.  It  is  not  possible  to  state 
accurately  in  figures  the  extent  of  the  influence  exercised  by 
each  of  these  factors,  and  for  this  reason  we  attach  greater 
importance  sometimes  to  the  one  and  sometimes  to  the  other. 
Sexual  intemperance  may,  perhaps,  account  for  the  circumstance 
that  gout  and  syphilis  go  very  often  together. 

The  same  factors  may,  though  less  frequently,  give  rise  to 
gout  in  people  who  are  not  hereditarily  predisposed  to  it,  and  we 
may  add  to  them  in  all  probability  as  a  predisposing  element, 
chronic  lead-poisoning. 

The  disturbances  caused  by  gout,  show  with  regard  to 
marriage  no  peculiar  characteristics.  Acute  attacks  run  as  a 
rule  a  similar  course  to  that  of  other  acute  diseases ;  after  their 
cessation  the  individual  affected  is  practically  in  the  same  con- 
dition as  he  was  before.  It  is  only  when  the  attacks  become 


282  HEALTH,  DISEASE,  MARRIAGE 

very  frequent  and  more  and  more  joints  get  affected,  that  is, 
when  the  disease  assumes  a  chronic  form,  that  the  matter 
assumes  a  different  aspect. 

Chronic  gout  leads  in  the  course  of  time  to  organic  changes, 
deformities  in  the  joints  which  interfere  with  their  use,  disease 
of  the  kidneys,  of  the  heart  and  vascular  system,  of  the  liver 
and  other  organs;  but  these  sequelae  do  not  as  a  rule  make 
their  appearance  until  late  in  life,  seeing  how  seldom  gout  affects 
young  persons,  so  that  they  hardly  ever  arise  at  a  time  when 
people  are  about  to  marry.  But  should  it  happen  that  a  man 
affected  with  chronic  gout — and  in  view  of  what  has  been  said  as 
to  the  predisposition  of  the  two  sexes,  it  is  almost  always  men 
that  suffer  from  this  disease — is  about  to  enter  the  matrimonial 
state,  his  future  wife  will  have  to  make  up  her  mind  not  only 
that  she  is  not  marrying  a  healthy  and  vigorous  man  who  will 
be  able  to  gratify  fully  her  desires,  sexually  or  in  other  direc- 
tions, but  also  that  she  will  probably  sooner  or  later  be  called 
upon  to  assist  and  nurse  her  husband  who  moreover  will  hardly 
reach  the  allotted  span  of  normal  life.  The  same  scruples 
would  have  to  guide  the  physician  in  the  case  of  a  young  man 
affected  with  severe  gout,  a  not  impossible  occurrence  where 
there  is  a  strong  hereditary  predisposition  and  injudicious  mode 
of  life. 

Apart  from  such  cases  there  is  no  necessity  to  oppose  mar- 
riage where  there  are  no  complications  accompanying  gout; 
sometimes  it  might  even  be  advisable  to  recommend  it  espe- 
cially where  there  is  reason  to  anticipate  in  consequence  of  the 
married  state  a  salutary  change  in  the  manner  of  life  of  the  indi- 
vidual concerned,  such  as  would  produce  the  disappearance  of 
the  above-mentioned  injurious  etiological  elements  of  the 
disease.  From  this  standpoint  it  might  appear  rational  to 
advise  young  bon-vivants  especially  if  coming  from  a  gouty 
stock  to  get  married. 

Regarding  the  married  state  it  is  the  duty  of  the  practitioner 
where  either  one  or  both  of  the  married  partners  suffer  from 
gout,  in  addition  to  the  necessary  treatment  to  protect  if  possible 
the  children  from  the  disease  or  to  counteract  the  same  by  recom- 
mending an  early  regulation  of  the  whole  mode  of  life  in 


CONSTITUTIONAL  DISEASES  283 

accordance  with  the  well-known  principles  relating  to  the 
subject. 

IV.  Obesity  (adipositas,  lipomatosis  universa- 
lis)  and  adipositas  dolorosa. — Obesity  from  the  stand- 
point of  marriage  is  important  first  on  account  of  its  etiological 
circumstances,  and  secondly  because  it  occasions  a  certain  amount 
of  disturbance  in  the  sexual  functions.  On  both  points  it  is  the 
wife  who  is  more  interested  than  the  husband. 

Etiological  conditions. — As  regards  the  etiological  con- 
ditions, obesity  rests  very  often  on  family  predisposition,  and 
is  consequently  inherited,  whilst  in  a  number  of  cases  it  appears 
as  an  acquired  disease.  The  frequency  of  inherited  obesity  is 
differently  estimated,  and  namely  for  various  reasons  apart 
from  the  general  fallacies  which  underlie  all  calculations  that 
depend  on  family  histories.  For  racial  peculiarities  and  climatic 
conditions  play  here  an  undeniable  part  probably  because  cer- 
tain elements  favouring  obesity  have  been  inherited  through 
many  generations.  It  is  well  known  f.  i.  that  the  women  of 
many  eastern  nations  are  very  frequently  obese,  a  condition 
which  is  not  only  not  undesired  but  rather  looked  upon  with 
great  favour. 

In  Central  Europe  the  family  predisposition  can  generally 
be  demonstrated  in  more  than  half  the  number  of  cases.  Thus 
Kisch  found  in  4,000  cases  of  lipomatosis  universalis  2,235  w^tn 
such  predisposition  (about  $6%)  ;  Chambers  22  out  of  38 
(nearly  60%)  ;  von  Noorden  more  than  70%,  and  Bouchard 
on  the  other  hand  31  only  out  of  86  cases  (36%) .x 

The  predominance  of  the  female  sex  becomes  apparent 
where  there  is  hereditary  predisposition,  already  during  child- 
hood, but  still  more  at  a  later  age,  past  the  prime  of  life,  that 
is,  at  and  after  the  climacteric  period;  in  men  also  obesity  is 
more  frequent  at  more  advanced  ages  than  in  their  earlier  years. 

In  addition  to  the  greater  prevalence  of  obesity  among 
women  and  older  men,  there  are  also  a  number  of  other  causes 


*£.  H.  Kisch,  Die  Fettleibigkeit.  Stuttgart  1888.— Chambers,  Corpulence 
or  the  excess  of  fat.  London  1850. — v.  Noorden,  Fettsucht  in  Nothnagel's 
Spec.  Pathologic  VII.  4.  1000. — Bouchard,  Ralentissement  de  la  nutrition. 
Paris  1890. 


284  HEALTH,  DISEASE,  MARRIAGE 

which  co-operate  in  producing  the  disease,  even  where  there 
is  no  familiar  predisposition  to  it.  As  such  we  have  to  name 
in  the  first  instance  an  excessive  (i.  e.,  disproportionate  to  the 
requirement)  consumption  of  food  and  especially  of  such  arti- 
cles of  diet  which  are  supposed  to  form  fat  or  reserve-material, 
that  is,  carbo-hydrates,  such  as  farinaceous  food  and  sweets; 
secondly  insufficient  physical  exercise,  by  which  as  it  is  well 
known  the  consumption  of  fat  is  diminished;  and  thirdly  a 
plenteous  consumption  of  alcoholic  liquors,  seeing  that  alcohol 
is  a  reserve-article  for  fat.  If  obesity  is  noticed  more  often  in 
wine  and  beer-drinkers  than  in  those  who  take  spirits  it  is 
because  that  part  of  the  population  which  furnishes  the  majority 
of  spirit-drinkers  consists  as  a  rule,  of  people  who  do  not  take 
a  great  deal  of  food  but  who  have  on  the  other  hand  more 
laborious  work  to  perform  than  beer  and  wine  drinkers,  a  cir- 
cumstance which  more  than  counteracts  the  influence  of  the 
alcohol.1 

Disturbances  in  the  sexual  function. — In  addition 
to  these  three  injurious  agencies,  the  first  two  of  which  are 
particularly  active  in  women  of  maturer  age,  there  is  a  further 
powerful  factor  in  the  insufficiency  or  absence  of  the  sexual 
function. 

The  importance  possessed  by  the  non-exercise  of  this  func- 
tion in  the  accumulation  of  bodily  fat  has  from  times  immemo- 
rial been  recognised  both  in  man  and  animals,  and  it  has  recently 
been  confirmed  experimentally  by  modern  investigators.2  These 
experiments  have  proved  conclusively  that  by  the  removal  or 
destruction  of  the  genital  glands — ovaries  or  testes — a  pre- 
disposition to  obesity  is  produced. 

This  phenomenon  explains  the  frequent  occurrence  of 
amenorrhcea  in  obese  women,  partly  also  that  of  sterility  and 


'Translator's  foot-note :  The  reader  should  bear  in  mind  that  this  passage 
refers  to  European  continental  conditions.  The  working-classes  in  England 
and,  I  believe,  in  America  also,  are  not  as  a  rule  given  to  spirit-drinking;  it  is 
beer  which  plays  here  the  principal  part.  This  may  however  explain  why  one 
sees  so  many  more  stout  people  on  the  continent  of  Europe  than  either  in 
England  or  America, 

'Loewy  and  Richter  in  Du  Bois-Reymond's  Arch.  f.  Physiologic  1889. 
Suppl.,  and  Centralblatt  f.  Physiol.  1902.  No.  17. 


CONSTITUTIONAL  DISEASES  285 

also  probably  why  in  those  cases  where  pregnancy  ensues  the 
mammary  glands  act  so  deficiently.  This  deficient  lactation 
is  most  likely  also  influenced  mechanically  by  the  atrophy  of 
the  glandular  parenchyma  through  the  weight  of  the  excess 
of  fat. 

Another  cause  of.  the  sterility  in  obese  women  is  the  mechan- 
ical hindrance  in  the  exercise  of  the  sexual  act  and  the  conse- 
quent prevention  of  conception  through  the  formation  of  fat- 
deposits  in  the  external  genitals.  Irritation  of  the  skin  and 
mucuous  membrane  near  and  in  the  vulva  caused  by  perspiration 
and  friction  between  the  folds  of  fat  (intertrigo,  vulviti-s,  etc.) 
may  have  a  similar  result. 

The  impotence  frequently  noticed  in  fat  men  probably  rests 
on  like  causes,  namely  in  the  first  instance  on  an  atrophy  or 
other  kind  of  degeneration  in  the  testicles  resulting  in  azoo- 
spermia,  which  E.  A.  Kisch1  found  in  9%  of  the  highly  obese 
men  whom  he  examined  in  this  respect.  The  sexual  desire  and 
erective  faculty  are  in  such  cases  as  a  rule  also  diminished,  and 
finally  there  is  often  a  distinct  mechanical  interference  with 
the  copulative  act  produced  by  the  mass  of  abdominal  fat  sur- 
rounding the  penis.  With  the  improvement  in  the  obesity  the 
sterility  due  to  this  cause  soon  disappears. 

Apart  from  the  disturbances  connected  with  the  sexual  life 
it  is  worth  noticing  that  there  are  also  others  in  direct  association 
with  obesity  of  which  the  principal  are  those  affecting  the  heart 
and  vascular  system  giving  rise  to  dyspnoea  and  congestive 
symptoms,  and  glycosuria  which  may  develop  into  a  regular 
form  of  diabetes.  The  latter  is  usually,  like  the  diabetes  occur- 
ring along  with  gout,  of  a  mild  character. 

We  may  sum  up  what  has  been  said  above  with  regard  to 
marriage  and  the  married  state  in  the  following  guiding  prin- 
ciples for  medical  men : 

Significance  With  regard  to  marriage.— There  is 
no  risk  attached  to  marriage  as  far  as  the  obese  husband  is 
concerned,  unless  we  deem  it  prudent  to  point  out  the  possibility 
and  significance  of  sterility  resulting  from  one  or  other  of  the 

1 Kisch,  \.  c.  p.  130. 


286  HEALTH,  DISEASE,  MARRIAGE 

causes  mentioned,  and  to  recommend  a  suitable  method  of  treat- 
ment, where  such  a  course  is  requisite.  The  latter  is  of  course 
also  indicated  if  the  obesity  and  its  consequences  arise  in  the 
course  of  married  life. 

In  the  female  sex  obesity  may  render  pregnancy  dangerous 
on  account  of  the  probability  that  the  disturbances  created  in  the 
circulatory  and  the  respiratory  organs  may  attain  serious  pro- 
portions. This  consideration  will  however  hardly  arise  in  the 
case  of  young  women  about  to  become  married,  since  obesity 
rarely  is  present  in  other  but  older  females.  Where  such  a 
thing  does  happen  and  an  obese  young  girl  or  widow  contem- 
plates marriage,  the  physician  must  call  her  attention  to  the 
dangers  she  is  incurring  and  at  the  same  time  point  out  the 
possibility  that  her  marriage  may  prove  sterile  from  one  or 
other  of  the  above-mentioned  causes. 

It  is  of  course  understood  that  the  treatment  of  the  obesity 
can  be  commenced  before  or  after  the  marriage,  just  as  can  be 
done  with  respect  to  all  disturbed  conditions  arising  from  it.  If 
the  treatment  does  not  succeed,  it  may  become  necessary  in  the 
event  of  pregnancy  occurring  to  take  into  consideration  the 
advisability  of  arresting  it  by  inducing  premature  labour  in 
order  to  obviate  danger  to  life.  The  principles  which  were  laid 
down  when  discussing  the  matter  under  Diabetes  will  guide 
the  medical  man  in  coming  to  a  decision.  (See  page  275.) 

Addition :—adipositas  dolorosa  (Dercum's disease). 
— This  affection  which  has  only  recently  been  described  as  a 
separate  disease,  occurs  in  two  forms :  ( I )  as  a  general  and 
diffuse  obesity  like  the  one  just  discussed  but  associated  with 
more  or  less  pain  over  more  or  less  extensive  surfaces,  and 
(2)  in  the  form  of  multiple  and  painful  lipomata. 

The*  significance  of  the  first  form  from  the  standpoint  of 
marriage  is  on  the  whole  similar  to  that  of  ordinary  obesity, 
except  that  the  pain  occurring  either  spontaneously  or  as  the 
result  of  pressure  may  necessitate  special  consideration  of  the 
disturbances  likely  to  ensue  in  consequence  of  the  sexual  act 
or  of  the  excessively  painful  character  of  an  eventual  labour. 

In  the  second  form  it  is  only  these  last-mentioned  difficulties 
which  will  at  least  once  make  their  appearance. 


CONSTITUTIONAL  DISEASES  287 

Generally  speaking  it  is  only  very  rarely  that  medical  advice 
can  be  sought,  by  sufferers  from  this  disease  in  connection  with 
the  contraction  of  marriage,  especially  as,  judging  from  the 
scanty  material  existing  on  the  subject,  it  is  principally  women 
at  and  after  the  climacteric  age  who  are  subject  to  it.1 

V.  Myxo edema. — Of  this  not  very  frequent  disease  we 
also  distinguish  two  types : 

(1)  The  infantile  form  of  myxoedema   (called  also  spo- 
radic cretinism).     It  begins  at  an  early  age  and  leads  in  the 
course  of  time,  usually  about  puberty,  to  such  grave  physical 
deformities  and  mental  disorders  that  the  marriage  of  an  indi- 
vidual affected  with  it  can  hardly  ever  come  into  consideration. 
The  successful  results  of  thyroid-gland  treatment  do  not  make 
any  difference  in  this  respect,  seeing  that  they  are  only  of  tem- 
porary duration  and  that  the  discontinuance  of  the  treatment 
is  rapidly  followed  by  a  return  of  the  symptoms. 

(2)  The  myxoedema  of  adults,  far  more  frequent  among 
women  than  men,  commences  generally  between  the  2Oth  and 
5Oth  year.     In  a  few  cases  an  hereditary  or  familiar  predispo- 
sition to  this  disease  has  been  observed.     Still  more  frequently 
cases  of  insanity  are  found  to  have  been  present  in  the  family 
or  nearest  blood-relations. 

The  marriage  of  an  individual  suffering  from  myxoedema, 
whether  it  be  a  man  or  a  woman,  can  naturally  form  the 
subject  of  a  medical  consultation  only  at  a  time  when  all 
or  almost  all  the  symptoms  of  the  disease  have  yielded  to  treat- 
ment, and  a  diagnosis  would  be  impossible  without  a  knowledge 
of  the  past  history  of  the  candidate  for  marriage.  In  such  a 
case,  the  doctor  would  be  the  victim  of  an  intentional  or  uninten- 
tional deception,  since,  were  he  to  give  his  consent  to  the 
marriage,  he  would  certainly  not  have  done  so  if  in  possession 
of  all  the  facts.  For  in  this  form  of  myxoedema,  too,  the 
results  of  treatment  are  transitory  only,  and  we  cannot  as  yet 
say  with  certainty  how  often  it  may  be  possible  to  repeat  the 
treatment  successfully  or  whether  the  symptoms  may  not  return 


1S.  P.  Strubing,  Arch.  f.  Dermat.  u.  Syphilis  Vol.  59.— Ch.  Fere,  Revue 
de  Med.  1901  Nr.  8. — Roberts,  Philadelphia  Med.  J.  1902  Nr.  17. — A.  Weiss, 
Wiener  klin.  Wochenschr.  1903  Nr.  17. 


288  HEALTH,  DISEASE,  MARRIAGE 

in  spite  of  the  repeated  treatment  and  prove  disastrous  in  some 
way  or  other  to  the  married  couple. 

These  symptoms  are  in  addition  to  the  cutaneous  changes 
which  have  given  the  disease  its  name,  and  besides  the  deform- 
ities due  to  these  changes :  marked  decrepitude  and  slowness  of 
motility,  feebleness  of  mind,  which  can  go  as  far  as  absolute 
imbecility,  and,  in  regard  to  the  sexual  functions,  an  inclination 
to  miscarriages.  There  are  also  frequently  noticed:  albumi- 
nuria  and  glycosuria,  a  combination  of  exophtalmic  goitre  and 
acromegaly,  all  of  them  signs  of  a  profound  disturbance  in  the 
metabolism.  They  require  treatment  during  as  well  as  before 
marriage. 

It  is  questionable  whether  the  hereditary  predisposition  to 
the  disease  observed  sometimes  can  be  removed  by  the  removal 
of  the  disease  itself.  There  is  no  risk  of  the  transmission  of 
myxoedema  from  husband  to  wife  or  vice-versa. 

VI.  Acromegaly. — This  disease  is  so  rare  that  for  this 
reason  alone,  it  will  only  be  on  exceptional  occasions  that  the 
medical  man  will  be  called  upon  to  deal  with  it  in  reference  to 
marriage.  Besides,  like  myxoedema  with  which  it  has  many 
points  in  common,  acromegaly  gives  rise  to  such  deformities  and 
disorders  that  it  is  extremely  unlikely,  at  least  when  the  disease 
can  be  diagnosed  with  some  certainty,  that  anyone  afflicted  with 
it,  whether  it  be  a  man  or  a  woman,  should  entertain  the  idea 
of  marrying  or,  if  so,  expect  to  be  loved  in  return.  From  a 
medical  point  of  view,  the  marriage  of  an  acromegalic  indi- 
vidual must  be  decidedly  opposed,  even  where  the  disease  is 
not  yet  fully  developed  or  where  there  is  only  a  suspicion  that 
it  is  present.  Because  although  the  disease  does  occasionally 
get  arrested,  and  although  one  or  other  of  the  symptoms  shows 
at  times  an  improvement,  acromegaly  is  on  the  whole  a  more  or 
less  rapidly  progressing  disease,  and  one  which  has  so  far  with- 
stood all  treatment. 

Of  all  the  symptoms  of  acromegaly  those  which  have  the 
most  serious  effect  upon  the  married  state  are  besides  the  gen- 
eral diminution  in  the  physical  and  moral  capability,  in  women 
amenorrhoea  and  sterility,  and  in  men  the  extinction  of  the 
sexual  desire. 


CONSTITUTIONAL  DISEASES  289 

There  is  no  fear  of  the  disease  being  conveyed  from  one 
of  the  married  partners  to  the  other. 

But  on  the  other  hand  a  direct  hereditary  transmission,  to 
the  offspring  of  acromegaly  as  a  whole  or  of  an  inclination  to 
giant  growth  in  the  whole  body  or  single  extremities,  has 
repeatedly  been  observed1  though  not  in  such  numbers  as  to 
justify  on  this  account  a  prevention  of  conception  or  the  inter- 
ruption of  an  eventual  pregnancy. 

VII.  Addison's  disease. — This  affection  which  in  spite 
of  isolated  reports  of  therapeutic  successes  must  still  be  looked 
upon  as  an  incurable  disease,  forms  when  fully  developed  an 
undeniable    contra-indication    against   marriage.      Where    not 
yet  fully  developed  and  where  the  diagnosis  cannot  be  made  with 
certainty  it  is  advisable  to  recommend  a  postponement  until 
such  time  when   a  decision  will  be  possible,   which  may  be 
expected  to  be  the  case  in  the  course  of  a  few  years. 

The  married  state  as  such  is  no  more  influenced  by  Addison's 
disease  than  by  any  other  chronic  ailment  conducive  to  decline. 

Nothing  is  known  as  to  the  contagiousness  of  the  disease 
or  as  to  its  hereditary  transmissibility. 

VIII.  Scrofula. —  Being  a  disease  which  both  in  its  origin 
and  in  its  course  is  peculiar  to  childhood  up  to  puberty  and 
slightly  beyond  it,  scrofula  as  such,  that  is  as  an  existing  con- 
dition of  ill-health,   hardly  ever  comes  into  consideration  in 
connection  with  the  subject  of  marriage  or  the  married  state. 
At  the  marriageable  age  it  is  perhaps  certain  processes  which 
stand  midway  between  scrofula  and  tuberculosis,  but  approach- 
ing more  the  latter,  such  as  lupus  and  the  so-called  scrofu- 
lous affections  of  the  joints  and  bones  that  might  demand  our 
attention  in  this  respect.     These  will  be  found  treated  in  other 
chapters  of  this  work  in  so  far  as  they  relate  to  the  subject  of 
marriage.      (See  Diseases  of  the  Skin,  and  Diseases  of  the 
Organs  of  Locomotion.) 

Apart  from  these  diseases,  there  are  some  consequential 


1S.  J.  Schwoner,  Ztschr.  f.  klin.  Med.  XXII.  1897  Festschr.  S.  202.— 
E.  Bonardi,  H.  Morgagni  1899  Nr.  9. — Breymann,  Deutsche  Ztschr.  f.  Ner- 
venheilk.  XVII.  1900. — A.  Frankel,  Verhandl.  des  Vereins  f.  innere  Med.  in 
Berlin,  1901,  April. 


290  HEALTH,  DISEASE,  MARRIAGE 

results  of  past  scrofulas  which  might  exhibit  a  certain  importance 
in  connection  with  the  subject  of  marriage,  as  f.  i.  scars  of  the 
skin,  of  the  mucous  membranes  or  of  the  lymphatic  glands 
along  with  possible  slight  deformities  or  functional  disorders, 
but  they  are  more  likely  to  constitute  aesthetic  rather  than 
medical  objections  and  will  not  as  such  often  come  under  the 
notice  of  the  physician. 

Delation  to  tuberculosis. — Of  greater  importance  is 
the  fact  that  scrofula  forms  a  predisposition  to  tuberculosis  and 
that  in  the  case  of  individuals  who  have  had  scrofula  there  is 
always  a  fear  that  they  will  sooner  or  later  be  attacked  by 
tuberculosis,  especially  of  the  lungs  and  larynx.  And  no  less 
important  is  the  other  fact  that  if  not  scrofula  itself  at  least 
the  predisposition  to  it  and  therefore  the  predisposition  to 
tuberculosis  is  transmissible  to  the  offspring  and  consequently 
hereditary. 

The  marriage  of  an  individual  who  has  had  or  still  has 
scrofula  may  therefore  give  ground  for  hesitation  firstly  because 
he  or  she  may  develop  tuberculosis  after  marriage,  an  occurrence 
likely  to  prove  more  or  less  disastrous,  and  secondly  on  account 
of  the  possibility  that  the  offspring  of  such  marriage  will  equally 
suffer  from  scrofula  and  the  predisposition  to  tuberculosis 
associated  with  it. 

But  although  these  scruples  are  theoretically  justified  it  is 
only  very  seldom  that  practical  conclusions  are  possible,  and 
unfortunately  the  medical  profession  is  able  to  achieve  the  least 
good  in  this  direction  just  where  it  is  mostly  needed.  It  is  well 
known  that  the  most  favourable  conditions  for  the  development 
and  dissemination  of  scrofula  are  created  not  only  by  inherited 
predisposition,  but  also,  and  even  without  such  predisposition, 
by  imperfect  nourishment,  by  a  deficiency  of  light,  air,  warmth 
and  cleanliness,  in  short  by  that  combination  which  we  are  in 
the  habit  of  calling  "bad  surrounding  circumstances." 

It  is  under  such  circumstances  that  the  poorer  classes  of 
the  population  live  and  suffer,  and  it  is  here  where  the  medical 
man  could  often  raise  his  voice  against  many  a  marriage  and 
prevent  by  words  of  advice  and  warning  the  procreation  of 
scrofulous  children.  But  these  very  same  classes  do  not  as  a 


CONSTITUTIONAL  DISEASES  291 

rule  seek  medical  advice  on  such  matters  and  in  the  exceptional 
cases  where  they  do,  they  seldom  adopt  it  for  reasons  which  it 
does  not  lie  in  the  power  of  the  doctor  to  remove. 

Among  the  well-to-do  classes,  on  the  other  hand,  scrofula 
need  not  be  regarded  as  an  obstacle  against  marriage,  at  any 
rate,  not  as  a  serious  obstacle.  Because,  as  already  mentioned, 
scrofula  has  in  the  first  instance  run  its  course  by  the  time 
marriageable  age  has  been  reached.  And  secondly,  because  the 
possible  dangers  arising  from  a  previous  or  still  existing  scrofula 
may  both  in  the  individual  affected  and  in  his  offspring  be 
counteracted  with  a  certain  amount  of  success  where  there  are 
the  necessary  means  and  will-power. 

Where  the  circumstances  are  favourable  there  is  conse- 
quently no  necessity  for  the  medical  man  to  oppose  the  marriage 
of  a  scrofulous  individual  even  where  there  are  still  some  traces 
of  the  disease  left ;  nor  will  he  under  similar  circumstances  have 
to  take  any  other  precautions  with  respect  to  the  offspring  of 
scrofulous  or  ex-scrofulous  parents  than  to  recommend  an  avoid- 
ance of  all  injurious  influences  in  the  mode  of  life  of  the  latter 
and  the  best  possible  hygienic  surroundings  for  the  mother  in 
the  case  of  pregnancy.  As  regards  the  children  it  is  desirable 
that  every  endeavour  be  made  that  they  receive  judicious  nurs- 
ing and  a  bringing-up  intended  to  make  them  strong  and 
resistant. 


IX 

Diseases  of  the   Blood  in    Relation   to 
Marriage 


IX 

DISEASES    OF   THE    BLOOD    IN  RELATION 
TO    MARRIAGE 

By  Professor  H.  Rosin  (Berlin) 

General  relations  between  blood-diseases 
and  marriage.  Influence  of  blood=diseases 
upon  marriage. — Among  the  diseases  which  may  exert  a 
far-reaching  and  lasting  influence  upon  marriage  those  of  the 
blood  are  of  especial  importance.  The  reasons  for  this  are 
manifold.  In  the  first  instance,  the  anomalies  of  the  blood 
which  occur  most  frequently  have  a  decidedly  chronic  character, 
and  are  included  among  the  constitutional,  some  of  them  even 
among  congenital,  diseases.  Though  they  are  usually  non- 
malignant  and  per  se  not  virulent  in  their  course  their  injurious 
effects  are  often  of  long  duration,  not  infrequently  hard  to 
remove  and  occasionally  altogether  unavoidable.  Another 
group,  fortunately  more  rare,  equally  of  long  duration  is  gen- 
erally fatal  in  its  issue  and  is  reckoned  among  the  severest 
diseases  which  we  know.  There  are  only  a  few  acute  disorders 
in  the  constitution  of  the  blood  which  occur  mostly  secondarily 
that  are  amenable  to  rapid  and  successful  treatment.  We  must 
therefore  expect  disturbances  in  the  happiness  and  duties  of 
married  life  if  it  is  only  on  account  of  the  long  duration  and 
partly  also  of  the  severity  of  these  diseases. 

But  affections  of  the  blood  are  injurious  in  their  effect  upon 
marriage  not  only  as  diseases  pure  and  simple,  they  have  also 
unfavourable  remote  influences  and  particularly  upon  the  sexual 
organs.  If  every  organic  disease  reacts  more  or  less  injuriously 
upon  the  other  organs  in  the  body,  this  is  especially  the  case  as 
regards  the  blood,  seeing  that  it  penetrates  into  every  part  of 


296  HEALTH,  DISEASE,  MARRIAGE 

the  organism  and  that  it  acts  as  the  intermediary  of  the  meta- 
bolic process  to  a  very  considerable  degree.  The  sexual  organs, 
especially  in  the  female  sex,  are  naturally  also  very  much 
dependent  on  a  supply  of  healthy  blood.  They  share  this 
requirement  with  the  other  organs.  It  is  however  well-known 
that  there  are,  besides,  certain  special  relations  between  the 
genital  organs  and  the  blood,  so  that  in  the  event  of  disease  of 
the  latter  the  former  may  suffer  in  consequence ;  this  is  especially 
the  case  with  married  people  and  particularly  so  in  married 
women.  We  know  quite  a  number  of  diseases  of  the  genital 
organs  of  married  women,  and  many  a  case  of  severe  pregnancy 
and  labour  as  well  as  cases  of  insufficient  lactation  which  are 
due  to  an  abnormal  condition  of  the  blood. 

We  have  also  to  take  into  consideration  the  unfavourable 
results  which  appear  in  the  offspring  as  a  consequence  of  blood- 
disease  in  the  parents.  Apart  from  the  circumstance  that  certain 
affections  of  the  blood  are  decidedly  hereditary,  there  are  a 
number  of  other  milder  but  also  lasting  constitutional  diseases 
of  the  blood  in  the  parents,  which  may  result  in  the  procreation 
of  a  weak  and  non-resistant  progeny,  who  require  extraordinary 
care  and  attention  and  destroy  the  happiness  of  married 
life. 

Of  no  less  import  is  the  influence  of  marriage  on  the  diseases 
of  the  blood,  though  not  in  those  severe  affections  which  have 
an  absolutely  unfavourable  prognosis.  The  congenital  diseases 
also  are  not  always  subject  to  any  influence  on  the  part  of 
marriage.  But  it  is  those  by  far  more  frequent  slighter  anoma- 
lies which  are  chronic  and  constitutional  that  often  experience 
through  marriage  a  complete  transformation.  In  the  man,  the 
more  orderly  habits  of  life,  the  greater  circumspection,  the  reg- 
ulation of  the  sexual  intercourse  occasions  an  improvement  in, 
or  disappearance  of,  the  disordered  blood-formation  previously 
in  existence.  The  same  factors  co-operate  in  the  woman  and  in 
her  case  it  seems  further  that  the  gratification  of  the  sexual 
desire  is  particularly  beneficial  in  its  effect  upon  the  activity 
of  the  blood-forming  organs,  and  in  relieving  former  menstru- 
ation troubles  which  caused  anomalies  of  the  blood.  Pregnancy 
especially  exerts  its  influence  upon  existing  blood-diseases  in  a 


DISEASES  OF  THE  BLOOD  297 

remarkable  manner.  The  latter  very  often  disappears  tem- 
porarily or  even  permanently  in  consequence  of  the  pregnancy, 
so  that  the  woman  owes  to  this  condition  the  first  enjoyment  of 
perfect  health  and  robustness. 

In  contrast  to  these  favourable  effects  of  marriage  upon  the 
blood  there  are  of  course  also  unfavourable  ones.  Frequently 
enough  we  see  blood-diseases  arising  through  and  in  the  course 
of  marriage.  This  is  rarely  the  case  in  man ;  at  least  we  know 
nothing  of  diseases  of  the  blood  in  man  which  may  be  due  to 
the  married  state,  unless  sexual  over-indulgence  gives  rise  in  its 
course  to  temporary  abnormalities  in  the  blood-formation,  or 
in  other  words  to  anaemic  conditions — a  most  rare  event  in 
married  life  and  one  which  occurs  perhaps  only  during  the 
honeymoon  or  shortly  afterwards.  In  the  woman  it  is  dif- 
ferent. In  her  case  diseases  of  the  genital  organs  of  all  kinds, 
including  those  based  on  gonorrhoeal  infection  may  produce, 
especially  through  hemorrhage,  severe  affections  of  the  blood. 
The  same  thing  applies  perhaps  even  to  a  greater  extent  to 
abnormal  pregnancy,  labour  and  child-bed. 

The  special  relations  of  the  individual  blood- 
diseases  to  marriage. — These  reciprocal  influences  be- 
tween marriage  and  blood-diseases  do  not  manifest  themselves 
equally  in  all  the  individual  forms  of  the  latter,  but  appear 
prominently  now  in  one  form  and  now  in  another.  It  is  there- 
fore necessary  to  consider  these  relations  specially,  and  this  we 
shall  now  proceed  to  do. 

The  sub-division  of  blood-diseases  cannot,  since  we  do  not 
as  yet  know  the  nature  and  anatomical  basis  of  many  of  them, 
take  place  from  uniform  points  of  view.  Sometimes  the  deter- 
mining feature  is  supplied  by  the  condition  of  the  blood  and 
the  anatomical  behaviour  of  the  blood-forming  organs,  as  well 
as  by  the  outwardly  visible  pathological  changes,  sometimes  by 
the  kind  of  the  course  of  the  disease  (acute,  chronic),  some- 
times by  the  etiology  (essential,  constitutional,  secondary,  infec- 
tious blood-diseases),  and  we  distinguish  finally  also  congenital 
and  acquired  affections.  In  the  following  remarks  we  shall 
retain  the  usual  method  of  classification,  but  we  shall  see  that 
from  the  point  of  view  which  interests  us  here  most,  namely 


298  HEALTH,  DISEASE,  MARRIAGE 

that  of  the  influence  of  marriage,  the  different  blood-diseases 
deserve  different  consideration. 

I.  Anaemia. — We  commence  with  the  anaemias.  Under 
this  name  we  include,  as  is  well-known,  a  large  and  hardly 
uniform  group  of  blood  diseases  which  exhibit  certain  common 
anomalies  in  the  blood  in  differently  marked  degrees,  namely 
poverty  of  haemoglobin,  a  diminution  in  the  number  and  size 
of  the  red  corpuscles,  and  reduction  in  the  dry  residue;  there 
always  is,  besides,  an  abnormal  paleness  of  the  skin  and  mucous 
membranes,  in  addition  to  a  number  of  characteristic  symptoms 
in  other  organs,  namely  pain  and  a  sense  of  fatigue  in  the 
organs  of  locomotion,  disordered  digestion,  affections  of  the 
sexual  organs,  headache,  etc.,  disturbances  which  we  designate 
as  functional  and  which  are  the  result  of  insufficient  nutrition 
on  the  part  of  the  diseased  blood. 

If  the  same  clinical  picture  is  common  to  all  the  different 
forms  of  anaemia,  we  cannot  draw  from  this  the  conclusion  that 
the  disease  of  the  blood-forming  organs  is  in  every  case  alike, 
seeing  that  we  know  so  very  little  about  it.  Anaemias  are 
moreover  the  result  of  so  many  different  causes  that  for  this 
reason  alone  it  seems  advisable  to  distinguish  several  forms  of 
them.  This  applies  especially  to  the  consideration  of  their 
relationship  to  marriage  in  connection  with  which  the  different 
causes  require  different  appreciation. 

Thus  one  of  the  most  important  and  most  frequent  forms  of 
anaemias  in  the  female  sex  is  chlorosis;  in  spite  of  its  common 
symptoms  it  especially  deserves  to  be  regarded  as  a  separate 
disease,  and  will  therefore  be  treated  in  a  special  chapter. 

Next  to  chlorosis  we  have  to  mention  essential  anaemia 
which  is  partly  congenital  and  partly  acquired  and  which  devel- 
oping into  a  constitutional  disease  is  often  brought  as  such  into 
the  marriage. 

Associated  with  this  is  that  form  of  anaemia,  which  is 
produced  by  an  unsuitable  mode  of  life  and  deficient  nourish- 
ment, and  which  plays  an  important  part  in  married  life. 

Very  prevalent  is  further  the  group  of  secondary  anaemias 
arising  in  consequence  of  haemorrhage  or  other  profuse  dis- 
charges or  after  all  sorts  of  organic  diseases.  These  also  have 


DISEASES  OF  THE  BLOOD  299 

a  great  influence  upon  marriage  especially  when  they  have 
passed  the  acute  stage  and  the  cause  having  disappeared  they 
develop  into  independent  chronic  diseases. 

All  these  groups  of  anaemias  just  mentioned  attack  the  male 
sex  far  more  rarely  than  the  female,  even  though  we  exclude 
chlorosis  for  the  present  altogether  from  our  survey.  First  of 
all,  the  adult  man  does  not  incline  to  that  independent  form 
of  anaemia  which  we  call  essential,  or  also  constitutional,  and 
which  without  presenting  the  typical  picture  of  chlorosis 
depends  nevertheless  on  a  disturbance  in  the  activity  of  the 
blood-forming  organs;  at  the  marriageable  age  this  anomaly  of 
the  blood  disappears  in  males  even  if  it  has  persisted  up  to 
puberty.  This  constitutional  anaemia  which  is  so  rare  in  men 
appears  the  more  frequently  in  women.  Many  of  them  who 
were  anaemic  from  birth  or  from  a  very  early  age  marry  when 
suffering  from  the  affection.  The  reason  lies  first  of  all  in  the 
great  predisposition  of  the  female  sex  to  this  disease,  and 
further  in  the  circumstance  that  the  mode  of  life  of  women 
at  the  age  of  puberty  and  shortly  before  marriage  does  not 
generally  conduce  to  improvement.  It  also  happens  occasion- 
ally that  women  contract  essential  anaemias  in  the  course  of 
their  married  life,  while  men  are  probably  always  free 
from  them.  More  equally  divided  between  men  and  women 
are  those  anaemias  which  we  attribute  to  an  improper  mode  of 
life  and  insufficient  nourishment;  but  here  also  the  female  sex 
shows  decidedly  a  greater  predisposition  and  at  the  same  time 
a  lesser  resistibility  against  the  injurious  influences.  From  the 
secondary  anaemias,  finally,  which  have  become  chronic,  women 
also  suffer  in  greater  numbers  than  men,  since  the  most  frequent 
causes  of  these  conditions  are  to  be  found  in  abnormal  haemor- 
rhages from  the  genital  organs  or  in  diseases  of  these  organs, 
while  haemorrhages  from  other  organs  occur  just  as  often  in 
women  as  in  men,  sometimes  even  oftener,  as  f.  i.  from  the 
stomach. 

Injurious  effects  of  anaemia  on  the  married  state. 
— The  injurious  effects  on  the  married  state  produced  by  the 
ansemia  of  one  or  both  of  the  married  partners  are  often  con- 
siderable though  they  do  not  proceed  from  diseases  dangerous 


300  HEALTH,  DISEASE,  MARRIAGE 

as  such  to  life.  Apart  from  general  physical  depression  which 
manifests  itself  in  a  constant  feeling  of  lassitude,  and  of  general 
discomfort  as  well  as  in  manifold  disturbances  in  the  various 
organs  of  the  body,  the  physical  inability  to  do  justice  to  the 
duties  connected  with  the  married  state  is  often  of  considerable 
prominence.  The  husband  derives  not  only  no  joy  from  his 
work,  but  his  capability  to  pursue  his  vocation  successfully  is 
diminished,  and  even  where  he  does  succeed  by  his  work  he 
has  no  energy  left  to  devote  himself  to  his  wife  and  family 
in  his  leisure  hours  as  is  the  duty  of  the  head  of  the  household. 
Absence  of  love  and  tenderness,  absence  of  active  interest  in 
the  welfare  of  wife  and  family,  neglected  education  of  the 
growing  children  who  are  left  entirely  to  strange  hands  are 
some  of  the  results  of  the  debility  and  of  the  desire  for  quietude 
which  accompany  anaemia. 

The  same  may  be  said  with  regard  to  the  more  frequently 
suffering  wife,  and  considering  her  greater  share  in  the  conduct 
of  the  household  and  in  the  rearing  of  the  children,  the  effect 
of  her  illness  on  the  marriage  is  even  more  serious  still.  But 
the  conditions  as  regards  the  wife  are,  besides,  far  more 
unfavourable  because  the  anaemias  are  often  provocative  of  an 
abnormal  state  in  the  genital  organs.  They  give  rise  f.  i.  to 
catarrhal  conditions  of  the  mucous  membranes,  to  anomalies 
in  the  menstruation,  which  if  they  existed  before  marriage  as 
a  consequence  of  anaemia  undergo  an  aggravation  in  the  course 
of  it.  Not  infrequently  there  is  a  complication  in  the  shape  of 
absence  of  the  conceptive  faculty.  On  the  other  hand,  preg- 
nancy, if  it  does  occur,  causes  in  anaemic  women  an  increase  in 
the  symptoms  which  are  still  further  aggravated  considerably 
by  the  labour  and  the  haemorrhage  connected  with  it  and  by  the 
troubles  of  child-bed;  it  is  well-known  that  severe  anaemia  con- 
stitutes occasionally  a  dangerous  complication  of  labour.  We 
also  know  that  in  anaemic  women  involution  after  labour  takes 
place  imperfectly,  that  lactation  runs  an  abnormal  course  and 
that  a  number  of  diseases  of  the  genitals  are  apt  to  occur  in 
consequence,  which  may  be  the  cause  of  endless  trouble  and  of 
an  unhappy  married  life. 

In  addition  there  is  the  hereditary  transmissibility  of  the 


DISEASES  OF  THE  BLOOD  301 

disease  to  the  offspring.  It  is  fortunately  no  fixed  law  that 
the  children  of  parents,  one  or  both  of  whom  were  affected  with 
constitutional  anaemia,  must  inherit  the  disease,  but  very  many 
of  them  are  born  with  abnormal  debility  which  can  be  success- 
fully combated  only  by  great  and  additional  care. 

Influence  of  marriage  on  anaemia. — If  we  now  ask 
ourselves :  Vice-versa,  what  influence  has  marriage  on  the  pro- 
duction and  the  course  of  anaemia  ?  we  may  give  something  like 
the  following  answer: 

It  may  be  said,  to  begin  with,  that  marriage  is  very  fre- 
quently the  source  of  origin  of  chronic  anaemias.  This  is 
certainly  rarely  the  case  as  regards  the  husband.  The  essential 
form,  as  already  mentioned,  hardly  ever  develops  in  married 
men,  and  secondary  anaemias  after  haemorrhages  or  diseases  of 
all  kinds  cannot  naturally  be  ascribed  to  the  married  state. 
Anaemic  conditions  may  possibly  be  caused  in  a  married  man 
by  an  unhealthy  mode  of  life.  This  applies  particularly  to  the 
poorer  classes.  In  their  case  marriage  means  occasionally  a 
material  deterioration  of  the  economic  position,  the  beginning 
of  poverty,  a  change  to  unfavourable  conditions  as  regards 
housing  accommodation,  and  nutrition.  Nor  can  it  be  said  that 
this  does  not  occasionally  happen  among  well-to-do  people  as 
well.  If  there  is  not  exactly  a  fear  of  starvation,  marriage 
means  at  times  with  them  also  an  abnormally  increased  demand 
on  the  earning  capacity  of  the  husband,  a  disproportionately 
greater  amount  of  work  or  professional  activity  under  excite- 
ments to  which  the  body  does  not  feel  equal.  In  addition  to 
this,  there  are  frequently  troubles  in  the  house  either  on  account 
of  the  wife's  illness  or  of  that  of  the  children,  or  lasting  and 
far-reaching  mental  worries  and  depressions.  Not  without 
injurious  influence  are  also  the  various  excesses  in  which  partic- 
ularly the  better  classes  are  wont  to  indulge  under  our  present- 
day  social  environments,  especially  those  prevailing  in  large 
towns:  prolonged  staying-up  in  over-filled  and  ill-ventilated 
rooms  after  a  day's  hard  work  instead  of  recuperating  sleep, 
and  the  consumption  of  excessive  quantities  of  food  and  drink. 
It  is  just  in  this  respect  that  marriage  among  the  better  classes 
brings  obligations  along  with  it  which  those  who  are  unmar- 


302  HEALTH,  DISEASE,  MARRIAGE 

ried  can,  though  not  always,  escape  more  easily  and  which  they 
are,  at  any  rate  in  their  younger  years  more  capable  of  fulfill- 
ing. All  these  injurious  conditions  are  capable  of  producing 
in  men  chronic  anaemias  if  not  other»serious  diseases. 

But  of  still  greater  import  in  the  causation  of  chronic 
anaemias  is  marriage  to  the  female  sex.  Apart  from  the  fact 
that  the  points  just  mentioned  naturally  apply  to  married 
women  as  well  as  to  married  men,  perhaps  to  even  a  greater 
extent,  important  causes  of  chronic  anaemia  are  to  be  found  in 
the  haemorrhages  from,  and  the  diseases  of,  the  genital  organs  to 
which  women  are  particularly  subject  during  the  course  of 
their  married  life,  far  more  so  than  during  their  virgin  state. 
Severe  loss  of  blood  at  the  end  of  pregnancy,  in  labour,  and 
child-bed,  diseases  of  the  uterus  and  uterine  membrane  in 
association  with  it  or  as  a  spontaneous  occurrence  which  are 
complicated  with  severe  haemorrhages  form  the  cause  of  chron- 
ically anaemic  conditions  which  have  developed  from  originally 
acute  anaemias.  Without  haemorrhage  also  it  is  possible  after 
long-continued  inflammatory  affections  of  the  genital  organs 
which  have  arisen  through  labour  or  through  infection  and 
also  spontaneously  or  even  through  lactation  for  chronic 
anaemias  to  develop  in  married  women. 

Finally,  women  are  occasionally  subject  to  the  essential 
form  of  anaemia  (without  any  known  etiology)  even  though 
they  are  already  married.  It  is  for  these  reasons  that  anaemias 
are  so  particularly  frequent  in  married  women,  and  that  mar- 
riage can  in  some  respects  be  considered  as  the  direct  cause 
of  certain  forms  of  anaemia. 

But  it  also  is  on  the  other  hand  possible  for  marriage  to 
exercise  a  beneficial  influence  upon  anaemic  conditions.  As 
regards  man  it  is  only  very  rarely  that  marriage  is  called  upon 
to  act  the  part  of  a  remedial  agent  in  constitutional  anaemia, 
because  as  already  mentioned  such  conditions  do  not  alto- 
gether often  occur  in  the  male  sex.  Where  they  do  exception- 
ally occur  marriage  is  likely  to  prove  beneficial  if  it  brings 
along  with  it  an  improvement  in  the  mode  of  life  and  in  the 
nutrition.  The  advantage  of  a  regulated  married  life  and  the 
care  and  attention  of  a  loving  wife  appear  more  fully  in  the 


DISEASES  OF  THE  BLOOD  303 

case  of  those  men  who  have  become  anaemic  through  former 
irregular  habits,  through  injudicious  nourishment,  through 
absence  of  sleep  and  excesses  of  all  sorts. 

The  remedial  character  of  marriage  in  its  effect  upon  the 
anaemia  is  still  more  apparent  in  the  married  woman.  We  shall 
return  to  this  point  when  discussing  the  subject  of  chlorosis.  It 
is  sufficient  here  to  mention  that  we  frequently  notice  a  com- 
plete disappearance  in  married  women  of  essential  anaemias  as 
well  as  of  secondary  anaemias  proceeding  from  the  genital 
organs.  It  would  seem  that  the  gratification  of  the  sexual  desire 
alone  acts  alteratively  on  the  anaemias  themselves  and  on  certain 
of  their  causes,  as  f.  i.  profuse  menstruation,  dysmenorrhoea, 
catarrh  of  the  mucous  membranes,  etc.  But  it  is  pregnancy 
which  is  very  often  the  most  pronounced  beneficial  remedy. 
Though  an  abnormal  pregnancy  and  a  difficult  labour  are  capa- 
ble of  producing  anaemia,  a  normal  pregnancy  is  on  the  other 
hand  often  beneficial  in  its  effect  upon  former  diseases  of  the 
genital  organs  and  former  deficient  blood-formation. 

Should  anaemic  individuals  marry  ? — The  last-men- 
tioned favourable  influence  of  marriage  brings  up  the  question 
whether  individuals  with  fully  developed  anaemia  should  be 
permitted  to  marry. 

As  regards  chlorosis  which  is  probably  the  form  of  anaemia 
that  occurs  oftenest  in  unmarried  women  the  reader  is  again 
referred  to  the  special  chapter  dealing  with  it. 

As  regards  the  other  froms  of  anaemia  the  following 
remarks  seem  to  be  indicated : 

Consideration  of  the  causal  region  in  secondary 
anaemias. — It  is  of  importance  to  ascertain  which  form  of 
anaemia  is  present.  For  in  secondary  anaemias  it  is  necessary  to 
consider  carefully  whether  the  causal  complaint  is  not  such  as  to 
be  prejudicial  or  inimical  to  marriage.  Very  often  there  is  hidden 
behind  an  anaemia  which  resists  all  treatment  an  insidious  tuber- 
culosis, which  has  as  yet  produced  no  manifest  pulmonary  or 
other  symptoms.  Chronic  nephritis  with  intervals  free  from 
albuminuria,  may  also  be  simulated  by  anaemia  where  the 
examination  is  not  very  carefully  conducted.  This  applies  also 
to  chronic  pyrexial  conditions,  slowly  progressing  suppuration, 


3o4  HEALTH,  DISEASE,  MARRIAGE 

typical  malaria,  parasitic  infection  of  the  intestines,  gastric  and 
duodenal  ulcers,  hereditary  syphilis,  severe  diseases  of  the  geni- 
tal organs,  and  malignant  tumours  at  the  beginning  of  their 
development.  All  these  diseases  must  be  excluded  with  cer- 
tainty before  it  is  possible  for  the  medical  man  to  give  his  con- 
sent to  the  marriage  of  an  anaemic  individual. 

Of  less  serious  import  but  nevertheless  demanding  careful 
examination  are  anaemias  after  continuous  loss  of  blood  which 
have  become  chronic.  Where  the  cause  lies  in  some  innocent 
ailment  such  as  frequent  epistaxis,  bleeding  haemorrhoids, 
menorrhagia  without  any  serious  disease  of  the  genital  organs 
there  is  no  need  to  refuse  permission  to  marry.  But  in  any  case 
the  necessary  treatment  for  the  removal  of  the  causal  disease 
must  be  instituted  as  soon  as  possible  before  marriage.  Against 
profuse  menstruation  it  will,  however,  not  always  be  possible 
to  interfere  successfully  and  we  shall  have  to  bear  in  mind  the 
fact  mentioned  above  that  the  causes  of  this  anomaly  are  fre- 
quently improved  by  marriage  or  removed  altogether.  The 
practitioner  will  therefore  let  himself  be  guided  by  the  same 
circumstances  as  in  chlorosis  (which  see). 

Anaemic  conditions  which  are  the  consequence  of  an 
unhealthy  mode  of  life  and  of  excesses  of  all  kinds  are,  as  has 
already  been  said  cured  during  and  by  marriage  under  certain 
circumstances.  Marriage  may  therefore  be  recommended  in 
such  cases,  but  of  course  only  if  an  improvement  in  the  method 
of  living  and  a  change  for  the  better  is  thereby  to  be  expected. 
Essential  anaemias  are  With  certain  restrictions 
no  obstacle  against  marriage. — Essential  or  constitu- 
tional anaemias  proper  if  not  abnormally  severe  in  character 
are  similarly  no  obstacle  against  marriage  seeing  how  often  a 
cure  is  actually  accomplished  by  marriage.  And  what  is  no 
less  noteworthy,  we  often  come  across  married  people  otherwise 
healthy  but  anaemic  who  are  by  no  means  so  incapable  to  fulfil 
their  obligations  as  one  would  expect  from  their  outward  appear- 
ance. Delicate  from  childhood  and  accustomed  to  great  cau- 
tiousness in  their  entire  mode  of  life,  endowed  with  a  good 
faculty  to  estimate  their  physical  strength,  they  are  more  care- 
ful in  the  hygiene  and  dietetics  of  their  married  life  than  many 


DISEASES  OF  THE  BLOOD  305 

others  who  though  in  full  vigour  are  apt  to  forget  themselves. 
They  know  instinctively  how  to  utilise  fully  to  the  benefit  of 
their  health  the  advantages  offered  by  the  married  state,  and 
how  to  avoid  excesses.  Every  experienced  doctor  knows  such 
individuals  who  are  affected  with  constitutional  anaemia  and 
are  for  this  reason  regarded  by  laymen  as  delicate,  but  who 
nevertheless  manage  to  steer  through  their  married  life  hap- 
pily, to  escape  serious  diseases,  to  become  with  advancing  age 
more  and  more  resistant  and  to  live  longer  even  under  circum- 
stances of  a  somewhat  unfavourable  character  than  many  with 
robust  constitutions.  Such  individuals  may  therefore  be  per- 
mitted to  marry,  even  where  there  is  no  certainty  that  the 
essential  anaemia  will  be  cured,  especially  if,  as  it  often  happens 
the  contracting  parties  are  of  equal  constitution.  Opposition 
to  such  marriage  on  the  part  of  the  medical  man  is  however 
justified  where  the  constitutions  of  future  husband  and  wife 
are  too  widely  different  from  one  another.  For  where  the  one 
is  suffering  from  constitutional  anaemia,  and  the  other  is  in  full 
possession  of  health  and  vigour,  the  contrast  in  the  two  consti- 
tutions and  in  the  physical  and  psychical  inclinations  associated 
with  them  may  easily  cause  disagreements  in  the  course  of  the 
married  life  which  will  affect  not  only  the  moral  happiness  of 
both  partners  but  also  subject  the  anaemic  husband  or  wife  to 
bodily  influences  not  in  consonance  with  the  former  cautious- 
ness and  careful  mode  of  life.  The  medical  man's  duty  is  to 
prevent  such  conditions  and  to  use  his  warning  advice  to  the 
best  of  his  ability. 

One  of  the  ill-results  of  essential  anaemia  from  the  stand- 
point of  marriage  which  has  already  been  mentioned,  namely 
the  injurious  effect  upon  the  offspring,  though  not  to  be  under- 
rated will  hardly  receive  much  practical  consideration  at  the 
arrangement  of  marriages.  For  in  the  first  place  an  hereditary 
predisposition,  especially  if  derived  from  one  side  only  does  not 
fortunately  always  manifest  itself.  But  where  as  it  often 
happens  both  father  and  mother  are  delicate  they  do  occasion- 
ally— not  always — bring  into  the  world  children  of  a  more  or 
less  degenerate  character  and  of  such  a  constitution  as  was  con- 
sidered by  the  Spartans  a  sufficient  ground  for  letting  them 


306  HEALTH,  DISEASE,  MARRIAGE 

perish  as  being  unfitted  to  undertake  the  obligations  of  life. 
Because  congenital  debility  often  kills  them  in  the  first  few 
months  of  their  lives:  rickets  and  scrofula  contribute  their 
share  in  producing  a  feeble  non-resistant  generation  which  if 
mentally  well  enough  developed  is  at  least  bodily  much  deteri- 
orated. And  though  the  parents  belong  to  that  class  of  indi- 
viduals who,  as  already  mentioned  exhibit  in  spite  of  their 
anaemia  a  certain  resistibility  against  the  injurious  influences  of 
life  this  quality  is  often  lost  in  those  descendants  who  possess 
a  double  hereditary  predisposition.  Nevertheless  it  is  impos- 
sible for  the  medical  man  to  prohibit  a  marriage  on  account  of 
such  hereditary  transmissibility.  His  duty  lies  rather  in  the 
direction  of  recommending  all  possible  endeavours  to  counteract 
the  hereditary  predisposition  of  the  children  by  increased  atten- 
tion and  greater  care  and  the  adoption  of  precautions  from  the 
very  earliest  moment,  such  as  judicious  nourishment,  hygienic 
measures  and  physical  exercise  at  the  proper  age,  which  will 
tend  to  transform  the  inherited  weak  constitution  into  a  healthy 
and  strong  one.  Unfortunately  this  is  a  consummation  which 
can  hardly  be  expected  in  the  case  of  the  poorer  classes  and 
death  will  continue  to  claim  his  numerous  victims  from  among 
the  children  of  poor  anaemic  parents. 

The  medical  man  will  have  to  devote  special  attention  to 
the  possible  influence  of  pregnancy  on  anaemic  women.  As 
already  mentioned  it  cannot  be  said  with  certainty  at  the  begin- 
ning of  a  marriage  whether  that  influence  will  be  beneficial  or 
injurious.  Where  the  latter  has  been  the  case  or  where  preg- 
nancy and  labour  are  directly  responsible  for  a  state  of  anaemia 
it  is  necessary  in  extreme  cases  to  insist  on  sexual  continency 
as  long  as  the  disease  remains  active  in  order  to  avoid  danger 
by  further  loss  of  blood  and  exhaustion. 

II.  Chlorosis. — We  will  now  consider  that  special  form 
of  essential  anaemia  which  we  call  chlorosis.  Its  close  connec- 
tion with  the  other  anaemias  is  evidenced  by  the  symptomatol- 
ogy which  is  in  many  respects  alike  and  by  the  circumstance  that 
it  is  benefited  by  the  same  therapeutic  measures.  Nevertheless 
chlorosis  may  be  separated  from  the  other  anaemias  as  a  special 
disease  peculiar  to  young  females,  the  more  so  as  most  authors 


DISEASES  OF  THE  BLOOD  307 

agree  in  ascribing  to  it  a  special  relation  to  the  genital  organs. 
It  is  questionable  whether  it  ever  appears  at  all  in  the  male  sex. 
In  any  event,  cases  described  as  chlorosis  appear  in  male  adults 
only  at  the  age  of  puberty,  that  is,  at  a  time  of  life  when  mar- 
riage is  with  them  as  yet  altogether  out  of  the  question.  For 
this  reason  we  have  to  consider  the  female  sex  exclusively  when 
treating  of  the  influence  of  chlorosis  on  marriage  and  vice-versa. 
The  disease  is  often  present  in  young  women  at  an  age  which 
precedes  immediately  the  entrance  into  the  married  state. 

Though  this  is  not  exactly  the  place  to  go  into  a  detailed 
description  of  the  symptoms  of  chlorosis  which  as  already  said 
are  not  dissimilar  to  those  of  anaemias  in  general,  it  is  advisable 
in  view  of  our  present  subject  to  touch  briefly  upon  the  relations 
which  the  disease  has  to  the  sexual  apparatus.  That  such  rela- 
tions do  exist  is  highly  probable,  but  objectively  they  are  not  by 
any  means  very  pronounced.  There  is  no  doubt  that  a  portion 
of  the  anomalies  which  the  genital  organs  of  chlorotic  women 
exhibit  is  the  result  of  nothing  else  but  deficient  nourishment 
on  the  part  of  the  diseased  blood.  Among  these  are  included 
as  in  other  anaemias,  disturbances  of  menstruation,  catarrhal 
affections  of  the  mucous  membranes  and  pain  in  the  respective 
organs.  More  significant  than  these  disturbances  in  the  genital 
organs  for  the  assumption  that  there  is  a  connection  between 
chlorosis  and  the  sexual  function  are  certain  subjective  sensa- 
tions. The  principal  of  these  is  a  remarkable  alteration  in  the 
wishes  and  inclinations  as  well  as  in  the  psychical  attitude  which 
chlorotic  women  manifest  occasionally  almost  as  markedly  as 
women  in  a  state  of  pregnancy.  Apathy,  general  depression 
or  a  striking  alteration  in  the  temperament,  often  become  quite 
marked  features  altogether  independent  of  the  bodily  condition. 
In  addition,  there  is  that  peculiar  abnormal  desire  for  certain 
articles  of  food  which  chlorotic  women  share  with  those  who 
are  pregnant.  Frequently  there  is  nausea  in  the  morning  espe- 
cially at  the  menstruation  periods.  Finally,  the  commencement 
of  the  disease  is  as  a  rule  accompanied  by  a  diminution  in  the 
sensual  inclinations — there  are  also  exceptions  in  an  opposite 
sense — ;  the  psychical  depression  extends  also  to  the  sexual 
sphere. 


308  HEALTH,  DISEASE,  MARRIAGE 


chlorotic  Women  marry?  —  Since  chlorosis 
generally  begins  about  the  time  of  sexual  maturity  and  lasts  for 
many  years,  resisting  all  treatment,  chlorotic  patients  or  their 
parents  may  often  find  themselves  confronted  with  the  question 
whether  marriage  is  in  their  case  permissible  or  desirable.  The 
medical  man  also  has  often  occasion  to  ask  himself  whether  girls 
suffering  from  chlorosis  may  marry  without  injury  to  their  own 
health,  without  detriment  to  the  eventual  offspring,  and  without 
disadvantage  to  their  married  life.  We  may  perhaps  answer 
this  question  in  the  following  manner:  Where  the  female 
concerned  is  still  very  young,  every  possible  attempt  must  be 
made  to  cure  the  disease  before  marriage  is  entered  into. 
Experience  shows,  that  the  majority  of  cases  of  chlorosis  are 
cured  before  the  age  of  20,  especially  if  the  proper  treatment  is 
instituted.  It  is  not  however  always  possible  to  wait  till  a  cure 
has  been  accomplished;  a  somewhat  advanced  age,  the  prospect 
of  a  happy  marriage,  an  existing  engagement,  and  other  circum- 
stances render  sometimes  a  quick  decision  necessary.  We  must 
therefore  rely  to  a  great  extent  upon  what  we  know  from 
experience,  namely  that  very  often,  perhaps  as  a  rule,  chlorosis 
disappears  completely  in  young  married  women  soon  after  their 
marriage  and  especially  with  the  beginning  of  pregnancy.  The 
above  mentioned  relations  of  chlorosis  to  the  genital  function 
receive  in  this  way  further  confirmation  through  the  favourable 
results  achieved  by  a  regulated  married  life.  The  doctor  may 
therefore  not  only  give  his  consent  to  the  marriage  of  a  chlorotic 
young  woman  where  suitable  treatment  has  been  either  impossi- 
ble or  unsuccessful,  but  he  may  under  certain  circumstances 
actually  recommend  it. 

We  may  thus  say  that  speaking  from  experience  chlorosis 
has  as  a  rule  no  injurious  effect  upon  the  development  of 
marriage,  and  what  deserves  to  be  specially  mentioned,  nor 
upon  that  of  the  offspring.  On  the  contrary,  marriage  is 
frequently  an  excellent  remedy  for  the  disease,  though  not 
always  applicable. 

It  must  not  however  be  forgotten  that  there  are  now  and 
then  cases  of  chlorosis  which  are  not  benefited  by  marriage, 
though  it  must  remain  an  open  question  whether  the  diagnosis 


DISEASES  OF  THE  BLOOD  309 

chlorosis  is  in  such  cases  justified,  and  whether  there  are  any 
chlorotic  married  women  at  all.  The  probability  is  that  these 
cases  do  not  belong  to  the  domain  of  chlorosis,  but  to  that  of 
constitutional  anaemia.  However  it  may  be,  we  shall  under  such 
unfavorable  circumstances  expect  to  see  the  same  injurious 
effects  arising  in  the  married  life  in  consequence  of.  the  disease 
both  as  regards  the  welfare  of  the  wife  as  well  as  the  happiness 
of  the  family  and  the  health  of  the  children,  as  we  had  occasion 
to  mention  above  when  discussing  the  anaemias  generally. 

Of  acquired  blood-diseases  it  is  principally  the  anaemias 
which  we  have  so  far  dealt  with  rather  minutely,  that  are  of 
importance  as  regards  their  relations  to  marriage.  The  ques- 
tion is  not  so  important  in  connection  with  other  acquired 
diseases  and  these  will  therefore  receive  the  following  brief 
consideration  only. 

III.  Haemoglobinaemia. — In  the  first  place  we  will 
mention    haemoglobinaemia     (hcemo globimiria] ,     and    namely 
that  idiopathic  form  which  appears  mostly  after  a  cold,  and 
which  in  contrast  to  the  symptomatic  form  produced  by  toxic 
agencies  (and  also  by  syphilis)  generally  runs  a  mild  course  and 
disappears  without  leaving  any  injurious  influences,  as  soon  as 
the  cause  is  removed.     It  is  not  necessary  to  prohibit  the  mar- 
riage of  patients  who  suffer  from  this  haemoglobinaemia,  which 
is  also  called  -paroxysmal  haemoglobinuria,  as  the  disease  can 
have  no  significance  as  regards  marriage,  the  more  so  as  it  never 
re-appears  so  long  as  the  injurious  influences  are  avoided.     It 
is  only  those  cases  that  become  complicated  by  chronic  nephritis 
which  acquire   a  serious  importance   from  the  standpoint  of 
married  life. 

IV.  The  haemorrhagic  diathesis. — The  same  may 
be  said  with  regard  to  the  group  of  blood-diseases  which  are 
included  under  the  name  of  hcemorrhagic  diathesis,  affections 
manifested  by  haemorrhages  through  the  skin  and  mucous  mem- 
branes without  a  diminution  in  the  coagulability  of  the  blood. 
They  are  diseases  which  run  quite  different  careers  and  which 
while  having  the  tendency  to  haemorrhages  as  a  common  symp- 
tom   vary    with    respect    to    other    important    signs.      Simple 
purpura,  which  consists  exclusively  of  cutaneous  haemorrhages 


310  HEALTH,  DISEASE,  MARRIAGE 

is  a  mild,  generally  apyrexial,  complaint  which  often  accom- 
panies rheumatic  affections;  where  the  latter  predominate  the 
disease  which  resembles  greatly  in  this  respect  certain  skin 
diseases  is  called  by  the  well-known  name  peliosis  rheumatica. 
The  purpura  hasmorrhagica  (morbus  maculosus  Werlhofii 
[ Werlhof's  purpura] )  the  pleonastic  name  of  which  is  probably 
meant  to  convey  an  idea  of  the  seriousness  of  the  haemorrhages, 
is  sometimes  a  harmless  apyrexial  ailment,  and  sometimes  a 
feverish  probably  infectious  or  toxic  disease  of  most  serious 
prognosis.  It  is  not  likely  that  both  forms  spring  from  the 
same  cause.  As  to  scurvy  (scorbutus)  it  is  due  to  faulty  nutri- 
tion, namely  prolonged  deprivation  of  fresh  meat  and  vegetable 
juices.  It  is  characterised  by  haemorrhages  from  the  gums 
which  are  especially  prominent  in  addition  to  haemorrhages 
from  the  skin  and  also  from  other  mucous  membranes. 

All  these  so-called  haemorrhagic  diatheses  may  acquire 
special  significance  in  the  married  state  during  pregnancy  only, 
and  in  labour  particularly,  since  most  dangerous  haemorrhages 
have  been  observed  in  the  latter.1  This  applies,  of  course,  only 
to  the  severer  forms  which  are  designated  as  morbus  maculosus. 
Scurvy  is  exceedingly  rare  in  Germany  and  hardly  ever  affects 
the  female  sex. 

As  regards  pregnancy,  to  begin  with,  Fellner2  has  estab- 
lished that  of  7  cases  which  he  found  in  the  literature  of  the 
subject,  3  ended  fatally.  The  embryo  also  suffers  through  the 
disease  in  the  mother.  Miscarriages  occur  in  consequence  of 
endometritis  haemorrhagica  or  of  placental  haemorrhages. 

The  labour  process  itself  is  naturally  highly  dangerous  and 
all  the  necessary  precautions  must  be  taken  in  time  to  avoid 
death  from  haemorrhage.  Postpartum  haemorrhage  during 
child-bed  can  also  frequently  cause  serious  danger  and  requires 
careful  attention. 


*Weise,  Ueber  uterine  Blutung  bei  morbus  maculosus.  Inaug.-Diss.  Brl. 
1884. — Wiener,  Ueber  haemorrhagische  Erkrankungen  bei  Schwangeren  u. 
Wochnerinnen.  Arch.  f.  Gynaek.  1887,  Vol.  31. — Stumpf,  Ueber  haemorrh. 
Erkrank.  im.  Wochenbett.  Arch.  f.  Gynaek.  1888,  Vol.  39— Phillies,  Influ- 
ence of  Purp.  haem.  on  menstruation  and  pregnancy.  Gynecological  Society. 
London  1891. 

*Fellner,  Die  Beziehungen  innerer  Krankh.  etc.  Leipsic  and  Vienna  1903. 


DISEASES  OF  THE  BLOOD  311 

Diehl  has  demonstrated  the  possibility  of  the  haemorrhagic 
diathesis  being  conveyed  to  the  child.  The  disease  though  not 
constitutional  is  therefore  occasionally  hereditary. 

But  though  this  hereditary  character  of  the  disease  cannot 
be  of  any  great  importance  as  regards  the  contraction  of  mar- 
riages, pregnancy  in  the  course  of  it  must  be  regarded  as  a  very 
undesirable  complication  which  ought  to  be  avoided  if  possible ; 
indeed,  where  the  haemorrhage  from  the  skin  and  mucous  mem- 
branes is  severe  and  the  consequent  anaemia  great  and  progres- 
sive the  artificial  interruption  of  the  pregnancy  is  indicated 
though  it  must  be  admitted  that  this  procedure  cannot  be 
instituted  without  running  the  risk  of  death  from  haemor- 
rhage. 

V.  Haemophilia. — We  come  now  to  the  consideration 
of  a  congenital  disease  of  the  blood  which  is  along  with  the 
anaemias  of  the  utmost  importance  with  regard  to  marriage. 
It  has  been  studied  carefully  for  the  first  time  at  the  end  of  the 
1 8th  century  (Fordyce,  Rave)  and  is  called  since  Schonlein 
named  it  so,  hemophilia. 

Nature  of  the  disease. — The  nature  of  the  disease  is 
not  yet  sufficiently  known  and  it  is  possible  that  it  depends  on 
an  insufficient  coagulability  of  the  blood  (Grandidier,  Lossen, 
Alex,  Schmidt],  that  is,  an  anomaly  in  that  fermentation  proc- 
ess which  comes  into  action  immediately  the  blood  leaves  the 
blood-vessels  or  as  soon  as  a  considerable  disturbance  of  the 
circulation  takes  place  within  the  latter,  particularly  through 
some  alteration  in  their  walls.  It  is  as  yet  questionable  whether 
absence  or  insufficiency  of  fibrin-ferment  constitutes  the  cause 
of  the  disease ;  possibly  the  lime-salts  necessary  for  coagulation 
are  not  present  in  sufficient  quantity.  The  researches  in  that 
direction  have  however  hitherto  proved  fruitless.  The  blood 
of  hasmophilics  behaves  somewhat  like  blood  when  it  has  been 
altered  by  the  addition  of  leech-blood  which  acts  towards  coagu- 
lation as  an  anti-fermentative.  Some  authors  think  the  disease 
is  also  due  to  an  alteration  in  the  blood-vessel-walls  (fatty 
degeneration  of  the  intima  of  the  capillaries,  according  to  Kidd 
and  Birch-Hirschfeld] ,  others  attribute  it  to  abnormal  narrow- 
ness of  the  vascular  system  and  want  of  proportion  between  its 


312  HEALTH,  DISEASE,  MARRIAGE 

calibre  and  the  quantity  of  blood  (Virchow,  Zimmermann, 
Oertel).  Koch  believes  in  infection  without  adducing  any 
proofs  in  support  of  his  opinion. 

General  dangers. — It  is  well  known  that  haemophilics 
are  on  account  of  the  diminished  coagulability  of  the  blood  in 
constant  danger,  the  more  so  as  with  the  exception  perhaps  of  old 
age,  the  condition  persists  throughout  life  and  seldom  undergoes 
an  improvement.  Slight  injuries  accompanied  by  haemorrhage 
especially  in  such  parts  of  the  body  which  are  difficult  of  access 
for  purposes  of  arresting  the  bleeding,  that  is,  internal  organs, 
and  diseases  of  the  latter  which  also  may  lead  to  haemorrhage, 
as  f.  i.  gastric  and  intestinal  ulcers,  haemorrhagic  inflammations 
of  the  kidneys  and  bladder,  diseases  of  the  genital  organs  accom- 
panied by  haemorrhages,  may  at  any  time  bring  the  haemophilic 
within  an  ace  of  bleeding  to  death. 

Dangers  during  married  life. — There  is  consequently 
not  the  least  doubt  that  marriage  constitutes  in  the  case  of 
haemophilics  under  all  circumstances  a  serious  danger.  When 
the  husband  suffers  from  the  disease,  the  worry  and  anxiety  lest 
something  serious  should  happen  in  connection  with  the  slightest 
accident  are  a  constant  source  of  trouble.  More  than  ordinary 
care  will  have  to  be  exercised  in  order  to  avoid  as  far  as  possible 
injuries  or  diseases  which  result  in  haemorrhage,  particularly 
affections  of  the  digestive  tract,  and  thus  save  the  family  from 
the  possible  loss  of  the  bread-winner. 

Haemophilia  is  however  of  totally  different  significance 
when  the  wife  is  the  affected  party.  In  her  case  haemorrhages 
from  the  genital  organs  (even  during  coitus)  particularly  in 
labour  and  in  child-bed,  are  of  extraordinary  danger.  Strange 
to  say,  normal  menstruation  proceeds  in  haemophilic  women  as 
a  rule  without  causing  any  serious  troubles.  But,  on  the  other 
hand,  abnormal  conditions,  especially  metrorrhagias  generally 
take  a  far  more  unfavourable  course.  The  danger  reaches  its 
highest  point  at  the  labour-act;  death  from  haemorrhage  occurs 
in  parturient  haemophilic  women  exceedingly  often. 

Distribution  of  haemophilia. — Fortunately  experience 
teaches  us  that  women  suffer  from  haemophilia  far  more  rarely 
than  men.  Thus  Grandidier  observed  in  200  haemophilic  fami- 


DISEASES  OF  THE  BLOOD  313 

lies  only  48  females  out  of  657  bleeders.    Stahel  found  in  4  gen- 
erations only  male  haemophilics. 

The  geographical  distribution  of  the  disease  is  according  to 
Grandidier  as  follows : 

Haemophilic      Number  of  M  p 

families  bleeders 


Germany 

93 

258 

236 

22 

England 

46 

141 

134 

7 

France 

20 

80 

75 

5 

North  America 

15 

61 

60 

i 

Russia 

7 

II 

7 

4 

Switzerland 

5 

48 

48 

Sweden  and  Norway 

3 

9 

6 

3 

Holland 

2 

9 

7 

2 

Belgium 

I 

4 

4 

— 

Denmark 

I 

3 

2 

I 

East  Indies 

I 

6 

5 

I 

194  630  584  46 

Germany  presents  therefore  the  greatest  number  even  in 
proportion  to  the  whole  population. 

Of  the  greatest  importance  however  for  the  marriage  of 
haemophilics  is  the  hereditary  transmissibility  of  the  disease  to 
the  offspring.  The  hereditary  conditions  of  the  affection  are 
strikingly  similar  almost  in  every  detail  to  those  of  colour-blind- 
ness (Homer,  and  others)  and  hemeralopia  (Ammann) .  It 
is  said  moreover  that  haemophilic  families  have  very  numerous 
descendants.  (Wachsmut.}  Of  course  not  all  the  children  are 
attacked  by  the  disease,  and  Grandidier  has  in  this  respect 
demonstrated  a  certain  mode  of  heredity.  Men  who  come  from 
haemophilic  families  procreate  with  healthy  women  who  do  not 
spring  from  haemophilic  families  as  a  rule  healthy  children 
though  they  are  themselves  bleeders.  Women  who  are 
descended  from  haemophilic  families  procreate  on  the  other 
hand  with  healthy  men  almost  always  a  few  haemophilic 
children,  even  though  they  are  not  themselves  bleeders.  It  is 
therefore  the  females  who  are  responsible  for  the  heredity  of  the 
disease ;  it  is  they  who  are  the  conductors.  Their  capability  to 
transmit  haemophilia  extends  as  a  rule  to  their  male  descendants. 
Grandidier  and  Fieli,  and  after  them  Hosli,  have  examined 
carefully  into  the  family  histories  and  the  hereditary  character 
of  the  disease  in  the  well-known  bleeder-village  Tenna  in  the 
canton  Graubiinden  and  have  arrived  at  the  following  conclu- 


HEALTH,  DISEASE,  MARRIAGE 

sion :  Haemophilia  is  oftenest  transmitted  hereditarily  from  the 
haemophilic  father  through  the  non-haemophilic  daughter  to  the 
male  grandchildren,  and  similarly  from  the  non-haemophilic  or 
haemophilic  mother  through  the  non-haemophilic  daughter  to 
the  male  grandchildren;  rarest,  directly  from  father  to  son. 
Another  family  of  bleeders  that  has  become  known  besides 
those  in  the  village  of  Tenna  is  the  family  of  Mampel  from 
Kirchheim  near  Heidelberg,  described  by  Chelius  in  1827,  by 
Untzenbrecher  in  1841  and  recently  by  Lossen.  Appended 
are  a  few  charts  of  the  disease  in  haemophilic  families: 


Genealogical  tree  of  the  family  Mampel,  after  Lossen. 
$  =  Bleeder 
Q  =  Female 
Q  =  Male 
+   =  Bled  to  death. 


Genealogical  tree  of  the  haemophilia  family  described  by  Gocht. 


DISEASES  OF  THE  BLOOD  315 

May  haemophilics  marry? — The  question  whether 
haemophilias  may  marry  acquires  under  such  conditions  a  special 
interest.  Since  heredity  plays  such  an  important  part,  and  the 
female  members  particularly  are  regarded  as  conductors  of  the 
disease,  it  is  the  duty  of  the  physician  according  to  Grandidier 
to  oppose  marriage  under  certain  circumstances.  We  may 
accordingly  lay  down  the  following  formulae : 

1.  Female    members   of   haemophilic    families   should   not 
marry  even  if,  as  is  generally  the  case,  they  are  not  themselves 
bleeders. 

2.  Male    members   who  are    not  themselves   bleeders  may 
marry  without  running  any  risks. 

3.  Male  bleeders  should  not,  on  account  of  the  hereditary 
character  of  haemophilia,  be  dissuaded  from  marrying  women 
belonging  to  non-haemophilic  families  unless  it  is  proved  that  in 
their  families  haemophilic  men  also  have  produced  haemophilic 
children. 

The  doctor  cannot  expect  to  see  his  advice  always  acted 
upon.  It  is  true  that  in  the  village  of  Tenna  the  female 
members  of  the  hsemophilic  families  have  vowed  among  them- 
selves never  to  marry,  but  such  a  decision  even  if  carried  out 
cannot  hope  to  find  many  imitators.  As  already  mentioned,  the 
families  of  bleeders  are  as  a  rule  very  large  and  the  number 
of  daughters  requiring  parental  support  would  be  too  great  and 
burdensome  were  they  in  all  cases  to  remain  unmarried. 

It  is  worth  while  to  mention  briefly  that  as  age  advances 
haemophilia  diminishes  in  severity  and  that  those  who  attain 
old  age  lose  the  disease  almost  entirely.  Finally,  we  must  bear 
in  mind  that  haemophilia  occurs  occasionally  as  a  constitutional 
disease,  either  congenitally  (case  of  Wendt}  or  acquired  in 
individuals  not  hereditarily  predisposed  to  it;  the  22d  year  is 
in  the  latter  case  regarded  as  the  extreme  age  for  the  commence- 
ment of  the  affection.  Such  individuals  may  form  the  starting- 
point  of  haemophilic  families.1 


the  more  recent  literature  on  haemophilia,  the  following  deserve 
especial  mention : 

1.  Kehrer,  Archiv  f.  Gynak.     1871. 

2.  Lessen,  Deutsche  Zeitschr.  f.  Chirurgie  1876. 


316  HEALTH,  DISEASE,  MARRIAGE 

VI.  Severe  diseases  of  the  blood. As  a  last  group 

we  have  left  for  consideration  the  diseases  of  the  blood  which 
are  included  among  the  most  serious  diseases  we  know,  and 
all  of  which  almost  without  an  exception,  are  fatal.  Among 
them  we  reckon  leukaemia,  primary  pernicious  anaemia 
(Birmer),  pseudoleukaemia,  and  splenic  anaemia.  (Banti's 
disease  cannot  be  regarded  as  a  disease  of  the  blood  proper  not- 
withstanding the  severe  affection  of  the  blood-forming  appara- 
tus, especially  that  of  the  spleen.) 

We  need  devote  but  little  space  to  the  consideration  of  these 
fatal  diseases  of  the  blood.  Patients  suffering  from  one  of 
them  will  hardly  ever  entertain  the  idea  of  marrying,  and  the 
medical  man  also  will,  of  course,  have  no  hesitation  in  declaring 
himself  against  it  under  any  circumstances.  Where  one  of 
these  dangerous  maladies  occurs  in  the  course  of  married  life, 
it  acts  as  a  catastrophe  which  soon  brings  the  married  state  to 
an  inevitable  dissolution.  And  so  there  is  really  nothing  more 
to  be  said  of  these  diseases  in  their  relation  to  married  life. 

Influence  of  pregnancy  on,  and  hereditary 
character  of,  the  diseases. — A  few  words  on  the  influ- 
ence of  pregnancy  on  the  course  of  these  diseases  and  on  the 
possibility  of  their  hereditary  transmissibility  are  nevertheless 
not  out  of  place. 

As  regards  leukaemia,  to  begin  with,  pregnancy  is  extremely 
unlikely  to  occur  in  the  course  of  it.  Fellner1  was  able  to  estab- 
lish with  certainty  that  only  in  3  out  of  14  cases  known  in 
literature  the  disease  had  existed  before  conception.  It  is  there- 
fore possible  that  the  predisposition  to  leukaemia  is  increased 


3.  Forster,  Gerhardts  Handbuch  der  Kinderkrankheiten  1878. 

4.  Kidd,  Med.-chirurg.  Transact.  1878. 

5.  Hosli,  Inaug.-Diss.  Basel  1885. 

6.  Wendt,  New- York  Med.  Record.    1887. 

7.  Fischer,  Inaug.-Dissert.  Munchen  1880. 

8.  Koch,  Die  Bluterkrankheiten.     Stuttgart  1889. 

9.  G.  Cohen,  Zeitschr.  f.  klin.  Med.  1890. 

10.  Wehle,  Ueber  Haemophilie  bei  d.  Geburtsakt.     Ges.  f.  Gyn.  Dresden 

1893 

11.  Litten,  Penzoldt-Stinzing,  Handb.  f.  Therapie. 

12.  Gocht,  Archiv  f.  klin.  Chirurgie,  Vol.  59,  1899. 

^Fellner,  Die  Beziehungen  innerer  Krkhn.  etc.     Leipzig  und  Wien   1903. 


DISEASES  OF  THE  BLOOD  317 

by  pregnancy,  an  opinion  which  Sanger1  does  not  share.  In  any 
case  pregnancy  exercises  a  very  injurious  influence  upon  the 
course  of  the  disease.  Rapid  growth  of  the  spleen  and  an 
exceedingly  high  increase  in  the  number  of  the  leucocytes  have 
been  observed  in  connection  with  it.  In  one  case  reported  by 
Stillmann  the  proportion  was  as  high  as  I  in  3. 

And  yet  the  conceptive  faculty  is  not  prejudiced  by 
leukaemia.  Cameron2  has  seen  repeated  pregnancies  during  the 
progress  of  the  disease.  Labour  occasions  sometimes  rapid 
aggravation  and  leads  to  coma  and  death.3  The  predisposition 
may  be  hereditarily  transmitted  to  the  children.  In  Cameron's 
case  all  the  children  had  a  tendency  to  leukaemia  and  one  of 
them  died  from  it  in  5  months.  Besides,  most  pregnancies  in 
the  course  of  leukaemia  end  fatally  a  few  hours  or  days  after 
the  premature  expulsion  of  the  embryo.  Only  4  cases  are 
known  which  did  not  terminate  with  death.  Sanger  thinks  that 
the  induction  of  premature  labour  should  be  postponed  until 
the  child  is  perfectly  viable;  he  recommends  artificial  abortion 
only  in  extreme  cases.  As  a  matter  of 'fact  Fellner  reports  that 
3  artificial  abortions  saved  the  respective  3  women.  Opinions 
like  those  of  Sanger  have  been  expressed  by  H.  Schroder.*  The 
severity  of  the  symptoms  must  be 'the  guide  for  the  treatment 
to  be  adopted  in  order  to  prolong  the  life  of  a  leukaemic  woman.5 

What  has  been  said  above  applies  also  to  the  other  fatal 
diseases  of  the  blood,  that  is,  primary  pernicious  anaemia,  splenic 
anaemia,  and  pseudoleukaemia.6  In  their  case,  too,  pregnancy 


^Sanger,  Uber  Leukaemia  bei  Schwangeren  und  angeborene.  Leukaemie. 
Arch.  f.  Gynakol.  1888.  Vol.  33- 

^Cameron,  Influence  of  leukaemia  on  pregnancy.  Internat.  Med.  Con- 
gress of  Washington.  Sept.  1887,  and  American  Journal  of  Sciences  1890. 

*Green,  Acute  Leukaemia  during  pregnancy.    New-York  Med.  Journ.  1888. 

'Schroder,  t)ber  wiederholte  Schwangerschaft  bei  lienaler  Leukaemie. 
Arch.  f.  Gynak.  Bd.  57. 

haggard,  Leukaemia  and  pregnancy.  Med.  News  July  1890. — Hilbert, 
Ein  Fall  mit  Schwangerschaft  komplizierter  acuter  Leukaemie.  D.  Med. 
Wochenschr.  1893  Nr.  36. 

V  Jaworsky,  t)ber  die  schwere  Anaemic  Schwangerer.  Centralbl.  f.  Gyn. 
1897. — Saniter,  Hochgradige  Anaemic  in  der  Schwangersch.  Centralbl.  f.  Gyn. 
1899  Vol.  19. — Commandeur,  Un  cas  d'anemie  pernicieuse  puerperale  etc. 
Progr.  Med.  Lyon  1900. 


3i8  HEALTH,  DISEASE,  MARRIAGE 

constitutes  a  most  dangerous  complication,  and  cases  of  these 
diseases  are  known  where  the  illness  commenced  subsequent  to 
the  beginning  of  the  pregnancy.  (Fellner.)  Labour  is  almost 
always  fatal,  while  prior  to  it,  that  is,  during  pregnancy,  the 
clinical  picture  is  not  much  more  serious  than  in  the  absence  of 
pregnancy;  on  account  of  the  hopelessness  of  the  cases  and  the 
danger  of  labour  all  that  is  perhaps  justifiable  in  the  interest  of 
the  child  is  to  induce  premature  labour. 


X 

Diseases  of  the  Vascular  System  in  Relation 
to    Marriage 


X 

DISEASES    OF  THE  VASCULAR  SYSTEM   IN 
RELATION  TO   MARRIAGE 

By   Professor   E.   v.    Leyden    (Berlin)    and 
W.    Wolff,    M.D.    (Berlin) 

Married  individuals  attain  an  average  age  of  60  years, 
those  unmarried  an  average  of  45  years.  This  we  see  from 
statistics.  According  to  Darwin  the  lower  mortality  of  the 
married  class  as  compared  to  the  unmarried  class  depends 
mainly  upon  the  exclusion  of  imperfect  types;  it  is  therefore  a 
result  of  natural  selection.  Perfect  individuals  marry  in  greater 
numbers  than  imperfect  ones.  Besides,  it  may  be  assumed  that 
the  greater  regularity  of  the  mode  of  living  resulting  from  the 
married  state  exercises  a  beneficial  influence  also  upon  the  dura- 
tion of  life  of  both  husband  and  wife.  Marriage  is  from  the 
hygienic  standpoint  as  well  as  from  the  aesthetic  and  social  points 
of  view  a  desirable  object  for  every  normal  adult  individual. 
It  must  however  be  remembered  that  marriage  brings  along 
with  it  certain  responsibilities,  the  fulfilment  of  which  requires 
perfect  health  of  body  and  mind. 

The  subject  "Diseases  of  the  vascular  system  in  relation  to 
marriage"  imposes  upon  us  the  duty  to  elucidate  from  the  medi- 
cal point  of  view :  firstly,  in  which  cases  conditions  exist  before 
marriage  which  would  constitute  the  latter  a  more  or  less  pro- 
nounced danger  to  the  health  of  the  husband  or  the  wife,  in 
other  words,  when  the  physician's  duty  is  to  warn  against  mar- 
riage; secondly,  we  have  to  answer  the  question,  what  should 
the  attitude  of  the  medical  man  be  where  under  analogous  pre- 
disposing circumstances  either  the  husband  or  the  wife  is 
attacked  by  disease.  In  order  to  be  able  to  answer  these  two 


322  HEALTH,  DISEASE,  MARRIAGE 

questions  we  must  ascertain  first  the  nature  of  the  injuries  which 
may  result  from  marriage  as  such.  Thirdly  and  finally,  it  is 
of  the  utmost  importance  to  establish  how  far  the  disease  of 
one  of  the  married  partners  may  influence  the  health  of  the 
children  born  from  such  marriages;  that  is  to  say,  how  far 
diseases  of  the  vascular  system  are  hereditary. 

The  principal  thing  with  regard  to  the  diseases  in  question 
is  the  reaction  of  marriage  on  the  patient.  As  far  as  the  wife  is 
concerned,  the  danger  lies  in  the  majority  of  cases  in  pregnancy, 
more  rarely  in  the  sexual  intercourse  as  far  as  the  husband  is  con- 
cerned, in  the  latter  only. 

The  worries  about  the  children  and  about  their  education, 
the  nursing  which  they  require  in  health  and  in  disease,  are  not 
quite  avoidable  in  any  family.  They  are  however  as  a  rule 
richly  compensated  for  by  the  joy  that  the  marriage  has  not 
remained  sterile. 

In  considering  the  reciprocal  relations  between  marriage 
and  various  diseases,  it  is  necessary  to  study  the  different  injuries 
which  marriage  may  occasionally  produce  in  each  case  indi- 
vidually, seeing  that  they  are  not  typical.  Financial  troubles, 
f.  i.  do  not  only  injure  both  sides,  but  they  affect  the  diseased 
husband  or  wife  more  than  the  healthy  one.  Psychical  disturb- 
ances happen  no  doubt  to  every  married  couple;  the  happier 
the  marriage,  the  more  rare  and  less  effective  they  are. 

Occupation  and  social  position  of  husband 
and  wife. — The  occupation  and  social  position  of  the  hus- 
band particularly,  as  the  head  and  bread-winner  of  the  family, 
must  receive  the  special  attention  of  the  physician.  A  wife 
suffering  from  heart-disease,  is  according  to  the  pecuniary  posi- 
tion of  her  husband  able  to  take  care  of  herself  or  obliged 
to  assist  him  in  the  earning  of  the  livelihood.  A  working- 
woman  who  marries  makes  a  change  for  the  better,  provided  her 
husband  earns  sufficient  to  maintain  her  and  her  family.  But 
she  does  not  improve  her  position  by  the  act  of  marriage  as 
such.  The  change  is  however  for  the  worse,  where  she  has  to 
contribute  by  her  own  work  to  the  maintenance  of  the 
family. 

In  the  first  instance  her  health  will  benefit  by  the  marriage, 


DISEASES  OF  THE  VASCULAR  SYSTEM     323 

in  the  second  it  will  suffer.  Where  marriage  occasions  an 
improvement  in  the  material  circumstances,  the  injuries  caused 
by  the  married  state  may  partly  be  counteracted. 

Prudent  marriages  in  the  sense  of  Darwin. — 
Where  a  contemplated  marriage  is  prompted  not  by  inclination, 
but  by  other  motives — and  of  such  there  are  very  many — the 
physician's  task  in  advising  against  it  is  a  far  lighter  one  than 
where  he  has  to  oppose  the  union  of  two  individuals  who  love 
each  other  truly.  We  know  from  experience  that  in  the  latter 
case  the  doctor  preaches  as  a  rule  to  deaf  ears,  and  that  in  the 
majority  of  cases  his  advice  is  not  followed. 

For  the  sake  of  the  health  of  the  offspring,  it  should  be  a 
general  law  that  the  parents  shall  be  free  from  the  predisposi- 
tion to  those  diseases  which  are  proved  to  be  hereditary  and 
which  in  fact  are  frequently  inherited.  According  to  the  social 
position  of  the  married  couple,  this  standpoint  is  of  more  or 
less  importance.  At  the  arrangement  of  marriages  of  crowned 
heads  for  instance,  the  question  of  the  state  of  health  of  the 
chosen  wife  or  husband  receives  the  most  careful  consideration. 
But  in  the  case  of  ordinary  mortals  also,  the  point  should  never 
be  neglected. 

Whoever  intends  to  contract  a  prudent  marriage  in  the  sense 
of  Darwin,  will  himself  select  a  healthy  partner  coming  from  a 
healthy  stock. 

In  passing  now  to  the  special  consideration  of  the  diseases 
of  the  vascular  system,  it  is  clear  that  generally  speaking  our 
principal  duty  is  to  answer  two  questions:  ist,  how  far  is 
heredity  concerned  in  the  diseases  under  notice;  2nd,  how  does 
marriage  affect  the  patients  themselves?  The  points  of  view 
resulting  from  the  answers  to  these  questions  govern  our  medi- 
cal action. 

We  divide  our  subject  into: 

I.  The  significance  of  diseases  of  the  heart  with  reference 
to  the  married  state. 

II.  The    significance    of    diseases    of    the    arteries    with 
reference  to  the  married  state. 

III.  The  significance  of  diseases  of  the  veins  with  reference 
to  the  married  state. 


324  HEALTH,  DISEASE,  MARRIAGE 

IV.  The  significance  of  diseases  of  the  lymphatics  with 
reference  to  the  married  state. 

We  begin  with  the  most  important  section. 

I.  Diseases  of  the  heart. — It  is  an  incontrovertible 
fact  that  there  are  families  in  which  diseases  of  the  heart  occur 
particularly  often.  Nothing  is  therefore  more  likely  from  a 
superficial  consideration  than  the  assumption  that  diseases  of 
the  heart  are  to  be  regarded  as  hereditary.  And  as  a  matter  of 
fact  this  heredity  is  looked  upon  as  a  reality  by  both  the 
educated  and  uneducated  public.  From  a  medical  point  of  view, 
however,  which  limits  strictly  the  conception  of  heredity  we 
arrive  at  quite  a  different  conclusion.  Most  affections  of  the 
heart  are  not  as  such  hereditary,  but  acquired.  Their  frequent 
occurrence  in  certain  families  can  be  accounted  for  by  other 
reasons.  Not  the  diseases  themselves  are  inherited,  but  the 
predispositions  which  may  lead  to  diseases  of  the  heart,  and 
these  predispositions  we  will  shortly  discuss  in  detail.  Heredi- 
tary in  a  true  sense  are  only  a  small  number  of  congenital 
affections  of  the  heart,  and  namely  only  those  the  origin  of 
which  we  suppose  to  be  due  to  congenital  malformations.  We 
will  therefore  consider  first  the  congenital  diseases  of  the  heart. 

i .  Congenital  diseases  of  the  heart. 

Consent  to  marriage  in  cases  of  congenital 
disease  of  the  heart. — The  question  of  heredity  interests 
us  here  in  an  entirely  special  sense.  We  have  to  ask  ourselves: 
Is  it  our  duty  in  the  case  of  a  man  or  woman  affected  with  a 
congenital  disease  of  the  heart  to  dissuade  from  marriage,  on 
account  of  the  possibility  that  such  marriage  may  result  in  the 
production  of  children  also  affected  with  heart  disease?  Or, 
shall  we,  where  either  one  or  the  other  side  of  a  married  couple 
has  a  congenital  affection  of  the  heart,  recommend  the  avoid- 
ance of  pregnancies?  Such  a  course  of  action  on  the  part  of  the 
medical  man  is  most  assuredly  not  justified.  True,  that  heredity 
is  in  occasional  observations  strikingly  manifest  (Vierordt},1 


lVierordt,  Die  angeb.  Herzkrank.     Nothnagel's  Spec.  Path.  u.  Ther. 


DISEASES  OF  THE  VASCULAR  SYSTEM     325 

but  on  the  other  hand  other  causes  are  just  as  frequently  given, 
f.  i.  syphilis  of  the  parents,  consanguinity  and  tuberculosis.  It 
is  a  well-known  fact  that  the  inclination  to  malformations  is 
hereditary.  But  we  have  as  medical  men  no  right,  for  instance, 
to  prohibit  the  marriage  of  a  man  who  has  hare-lip,  because 
there  is  a  risk  that  he  may  eventually  bring  children  into  the 
world  affected  with  malformations,  perhaps  in  some  other  part 
of  the  body.  Besides,  there  is  the  important  circumstance  to  be 
remembered,  that  in  diagnosing  at  a  later  period  of  life  congen- 
ital disease  of  the  heart  we  are  not  always  in  a  position  to 
decide  whether  the  affection  rests  on  malformation  or  arrest  of 
development,  or  on  foetal  endocarditis  or  on  both  these  factors. 
With  respect  to  heredity,  infectious  foetal  endocarditis  is  of 
course  of  no  consequence. 

But  even  if,  judging  from  what  has  been  said  above,  we 
were  justified  in  declaring  our  opposition  against  such  mar- 
riages, we  should  only  in  very  rare  cases  have  practical  opportu- 
nities of  doing  so,  since  no  more  than  an  insignificant  number 
of  individuals  with  congenital  heart-disease  attain  marriageable 
age.  On  the  other  hand,  we  are  often  confronted  with  the 
second  of  the  two  questions,  namely :  is  there  any  danger  in  mar- 
riage for  people  with  congenital  heart-disease? 

Let  us  now  consider  somewhat  more  closely  each  of  the  con- 
genital affections  of  the  heart. 

Almost  half  the  number  of  the  published  cases  of  congenital 
affections  of  the  heart  relate  to  pulmonary  stenosis,  (de  la 
Camp.y 

Further,  Peacock  has  established  that  of  the  individuals  with 
congenital  heart-disease  who  become  more  than  12  years  old, 
more  than  4/6  are  affected  with  stenosis  or  atresia  of  the  pul- 
monary artery.  But  the  patients  who  live  more  than  12  years 
also  have,  apart  from  a  few  exceptions,  only  a  limited  duration 
of  life.  Vierordl  calculates  the  average  duration  of  life  in 
pulmonary  stenosis  at  9.36  years.  Patients  with  pulmonary 
stenosis  who  have  withstood  well  their  early  childhood  generally 
succumb  to  tuberculosis;  in  some  of  them  disturbances  of  com- 


Camp.  Congenit.  Herzleiden  in  "Deutsche  Klinik." 


326  HEALTH,  DISEASE,  MARRIAGE 

pensation  appear  at  a  time  when  life  begins  to  make  great 
demands  upon  body  and  mind,  that  is,  when  people  are  grown 
up.  To  these  increased  demands  the  diseased  heart  is  not  equal. 
Supposing,  however,  that  we  have  before  us  a  patient  with 
pulmonary  stenosis,  we  shall  naturally  be  guided  in  the  presence 
of  this  valvular  disease  by  the  same  principles  which  apply  in 
the  case  of  acquired  valvular  diseases,  and  which  we  shall 
discuss  later  on. 

There  remains  but  very  little  yet  to  be  said  with  regard  to 
the  other  congenital  affections. 

The  congenital  disease  next  in  frequency  is  according  to 
de  la  Camp  the  stenosis  of  the  aorta  at  the  entrance  of  the 
ductus  arteriosus,  which  has  a  fairly  favourable  prognosis. 
Favourable,  and  when  not  complicated,  as  a  rule  undiagnosable 
is  the  patency  of  the  foramen  ovale.  Finally,  the  prognosis  is 
also  favourable  in  those  cases  where  the  ductus  arteriosus 
remains  open.  More  than  half  the  number  of  patients  exceed 
the  age  of  puberty.  Observations  have  also  been  published 
of  severe  forceps-labours  and  consequently  of  pregnancies  which 
were  well  born,  (de  la  Camp.}  The  other  congenital  diseases 
of  the  heart  offer  an  absolutely  unfavourable  prognosis  as 
regards  life  and  do  not  therefore  come  within  the  sphere  of 
our  considerations. 

Congenital  stenosis  of  the  aorta. — In  consider- 
ing the  congenital  defects  of  the  heart  we  must  not  forget  to 
mention  finally  an  important  anomaly,  namely  the  congenital 
narrowness  of  the  aortic  system.  According  to  Vierordt,  those 
individuals  in  whom  this  narrowness  of  the  aortic  system  attains 
serious  proportions  succumb  as  a  rule  in  early  manhood  from 
weakness  of  the  heart,  because  the  latter  is  not  equal  to  the 
normal  task  life  imposes  upon  it.  Vierordt  himself  points  out 
that  with  greater  care  a  more  advanced  age  would  probably 
often  be  reached.  For  this  it  would  above  all  be  necessary  to 
watch  the  symptoms  which  such  an  hypoplasia  of  the  aortic 
system  produces.  Now,  the  main  symptom  is  chlorosis,  the 
close  connection  of  which  with  the  disease  we  are  now  consider- 
ing was  first  demonstrated  by  Virchow.  Although  according 
to  him  the  question  of  the  congenital  stenosis  of  the  aorta  is  not 


DISEASES  OF  THE  VASCULAR  SYSTEM     327 

a  purely  gynaecological  one,  that  is,  although  the  abnormality 
occurs  in  men  as  well  as  in  women,  chlorosis  is  nevertheless  pre- 
eminently a  disease  of  the  female  sex.  The  most  favoured  age 
is  the  time  of  puberty  and  the  years  subsequent  to  it. 

The  very  fact  that  chlorosis  is  in  many  cases  curable  renders 
it  from  our  point  of  view  a  very  important  disease.  The  task 
of  the  physician  is  in  such  cases  a  gratifying  one,  for  although 
he  will  as  a  rule  in  the  presence  of  chlorosis  advocate  a  post- 
ponement of  the  marriage,  he  will  seldom  find  it  necessary  to 
forbid  it  altogether.1  Where  chlorosis  makes  its  appearance  in 
a  woman  already  married,  the  avoidance  of  pregnancy  must  be 
recommended  until  an  improvement  has  taken  place.  During 
the  act  of  labour  haemorrhage  must  be  restricted  as  much  as 
possible. 

As  regards  the  diagnosis,  the  systolic  murmur  present  in 
chlorosis  will  hardly  occasion  a  confusion  with  mitral  regurgi- 
tation  if  all  the  symptoms  are  carefully  considered.  In  1900 
Rosen f eld2  published  a  few  cases  from  Naunyn's  clinic  of  mitral 
stenosis  in  chlorosis  which  were  due  to  a  congenital  stenosis  of 
the  mitral  orifice.  The  more  the  affection  of  the  heart  pre- 
dominates in  such  cases  over  the  chlorosis,  the  more  unfavour- 
able the  prognosis  naturally  is.  Nevertheless  we  shall  apply 
Peter's  formula  quoted  by  Rosenfeld:  "Filles  pas  de  mariage, 
femmes  pas  de  grossesses,  meres  pas  d'allaitement"  in  the 
severest  cases  only.  (No  marriage  for  girls.  No  pregnancy 
for  married  women.  No  lactation  for  mothers.)  From  our 
point  of  view  these  cases  are  similar  to  acquired  mitral  stenosis 
to  which  we  shall  return  while  considering  the  acquired  valvular 
defects  which  claim  our  attention  next. 

2.     Acquired  valvular  defects. 

Acquired  diseases  of  the  heart. — In  acquired 
valvular  diseases  of  the  heart,  heredity  does  not  in  a  strict  sense 
play  any  part  whatever.  But,  as  already  mentioned,  there  are 
no  doubt  families  in  which  demonstrably  non-congenital  diseases 


Compare  Rosin,  p.  308. 

'Rosenfeld,  Ein  Beitrag  z.  Lehre  d.  chlorot.  Mitralstenose.  Inaug. -Dissert. 
Strassburg. 


328  HEALTH,  DISEASE,  MARRIAGE 

of  the  heart  also  occur  exceedingly  often.  This  frequent  occur- 
rence is  explained  by  the  etiology,  to  which  we  will  now  devote 
a  few  brief  remarks. 

Valvular  lesions  are  mostly  the  remains  of  endocarditic 
affections,  which  in  their  turn  are  oftenest  caused  by  acute  artic- 
ular rheumatism.  But  the  exciting  agents  of  almost  all  other 
infectious  diseases  are  also  capable  to  settle  on  the  valves  and  to 
produce  endocarditis.  We  have  only  to  mention  gonorrhoea, 
pneumonia  and  influenza.  Experimentally  it  has  been  possible 
to  create  endocarditis  in  animals  by  means  of  almost  all  bacteria, 
though  not  without  previous  injury  to  the  valves.  (F.  Meyer.1) 
It  has  also  been  proved  that  the  chronic  infectious  diseases, 
syphilis  and  tuberculosis,  may  occasionally  give  rise  to  diseases 
of  the  heart.  (Michaelis.)2 

The  second  most  frequent  cause  of  chronic  endocarditis  is 
arterio-sclerosis ;  here  the  same  process  which  affects  the  blood- 
vessels takes  place  in  the  valves,  most  frequently  at  the  aorta. 
The  valvular  defects  noticed  in  connection  with  gout  are  also  as 
a  rule  a  consequence  of  concurrent  arterio-sclerosis.  A  few 
cases  have  been  described  where  genuine  uratic  endocarditis  has 
been  inferred  from  a  deposit  of  salts  on  the  valves,  but  the  pres- 
ence of  uric  acid  has  been  demonstrated  only  a  few  times  includ- 
ing a  case  of  Lancereaux  in  which  however  the  patient  in  ques- 
tion had  never  suffered  from  gout.  For  this  reason  Minkowski 
considers  endocarditis  in  gout  to  be  purely  arterio-sclerotic. 

As  experience  shows  that  the  predisposition  to  articular 
rheumatism  is  sometimes  hereditary,  and  as  heredity  plays  in 
arterio-sclerosis  an  important  part,  of  which  more  anon,  this 
explains  sufficiently  how  it  is  that  cardiac  affections  occur  fre- 
quently in  certain  families.  But  neither  the  one  predisposition, 
nor  the  other  justifies  the  physician  to  withhold  his  consent 
to  a  marriage.  His  duty  is,  however,  where  such  a  tendency 
to  heart-disease  exists  in  a  family,  to  call  the  attention  of  the 
parents  to  it,  so  that  they  may  as  far  as  possible  avert  it  in  their 
children  either  by  inuring  them  against  the  rheumatic  inclination 
or  by  inducing  them  to  lead  a  suitable  mode  of  life. 


1F.  Meyer,  Experim.  Endocarditis  in  v.  Leyden-Festschrift. 
*M.  Michaelis,  Ueber  Endocarditis  in  "Deutsche  Klinik." 


DISEASES  OF  THE  FASCULAR  SYSTEM     329 

We  will  now  pass  to  the  most  important  question :  how  does 
marriage  affect  the  patient  subject  to  heart  disease? 

Already  in  the  year  1893  one  °f  us  (v-  Leyden)  has  in  a 
lecture  "On  the  complication  of  pregnancy  with  chronic  disease 
of  the  heart"  before  the  society  of  medical  officers  to  the 
Charite-Hospital,  taken  up  a  position  in  this  question,  which 
must  occupy  a  front  place  in  the  present  contribution.  Although 
the  views  expressed  on  that  occasion  have  often  been  opposed 
down  to  the  present  day  chiefly  by  gynaecologists  who  are  as 
much  interested  in  this  matter  as  the  physicians  who  devote  them- 
selves to  internal  medicine,  we  still  think  we  are  entitled  to 
adhere  to  our  opinion  notwithstanding  the  fact  that  our  hopes 
for  an  improvement  in  the  methods  of  artificially  inducing 
premature  labour  have  hitherto  not  been  realised. 

Pregnancy  and  valvular  disease. — Let  us  con- 
sider first  those  disturbances  which  are  capable  during  preg- 
nancy and  labour  of  influencing  injuriously  the  condition  of 
women  affected  with  heart  disease.  The  number  of  these  dis- 
turbances is  very  great,  and  we  emphasize  that  it  is  not  sufficient 
to  look  for  one  single  causal  factor,  but  that  it  is  necessary  to 
pay  regard  to  the  whole  of  the  circumstances  which  act  unfavour- 
ably on  the  affections  of  the  heart.  Some  authors  prefer  to  look 
at  the  matter  from  one  point  of  view  only;  a  few  have  accused 
the  hypertrophy  of  the  heart,  others  the  insufficiency  of  the 
respiration  or  the  upward  pressure  of  the  diaphragm,  and  others 
again,  the  diminution  in  the  blood-pressure  after  labour.  Zweifel 
has  expressed  himself  thus :  labour  is  an  over-exertion,  and  this 
over-exertion  on  the  part  of  the  heart  causes  injuries.  This 
factor  is  undoubtedly  of  great  importance,  but  many  others  are 
also  concerned,  and  any  one  of  them  in  particular  or  several  in 
combination  may  in  each  individual  case  turn  out  to  be  of 
decisive  moment. 

The  threatening  influences  affect : 

i.  The  heart. — The  question  of  the  hypertrophy  of  the 
heart  in  pregnant  women  has  in  medical  literature  always  played 
an  important  part,  and  is  playing  it  partly  even  at  the  present 
day.  In  France  Larcher  has  first  in  1825-26  laid  down  the 
theory  of  the  hypertrophy  of  the  left  ventricle  during  preg- 


330  HEALTH,  DISEASE,  MARRIAGE 

nancy.  He  examined  the  hearts  of  130  women  most  of  whom 
had  died  in  child-bed,  and  came  to  the  conclusion  that  under 
normal  circumstances  the  heart  is  enlarged  during  pregnancy, 
that  this  hypertrophy  affects  as  a  rule  the  left  ventricle  and  the 
left  auricle,  that  it  amounts  to  between  1/4  and  1/3  of  the 
normal  thickness,  and  that  it  disappears  gradually  during  lac- 
tation. The  results  of  this  examination,  supported  in  France 
especially  by  Ducrest  and  Durosiez,  have  often  been  doubted 
in  Germany  and  namely  by  Fritsch,  Lohlein  and  Wessner. 
They  relied  chiefly  upon  the  authority  of  Gerhardt  who  had 
demonstrated  that  the  measurements  given  by  Larcher  and 
Ducrest  fall  within  the  limits  of  normal  conditions.  Never- 
theless, the  supposition  that  a  certain  amount  of  hypertrophy 
of  the  heart  occurs  in  pregnancy  finds  as  yet  occasional  sup- 
porters, and  even  Macdonald  thinks  that  a  certain  degree  of 
it  is  probable  on  account  of  the  greater  work  which  the  heart 
has  to  perform  during  pregnancy.  Among  English  authors 
Peacock  is  of  the  opinion  that  a  certain  amount  of  hypertrophy 
does  exist. 

Anyhow,  we  cannot  at  the  present  day  attach  any  particular 
importance  to  this  hypertrophy,  not  even  in  the  case  of  women 
affected  with  chronic  heart-disease.  It  is  however  in  so  far  a 
point  worthy  of  consideration  as  it  confirms  somewhat  the 
grounds  upon  which  it  is  assumed  that  the  heart  is  called  upon 
during  pregnancy  to  perform  a  greater  amount  of  work. 

2.  The  influence  of  pregnancy  upon  the  heart  is 
further  proved,  as  Lohlein  has  shown,  by  the  fact  that  not 
infrequently  accidental  murmurs  are  observed  in  pregnant  and 
puerperal  women,  apart  from  any  fresh  occurrence  of  endocar- 
ditis, which  disappear  soon  after  labour,  during  child-bed. 

3.  As  regards  the  activity  of  the  heart,  it  is  said  that  its 
beating    is    usually    accelerated    during    the    last    months    of 
pregnancy. 

4.  Of  still  greater  interest  is  the  reduction  of  the  pulse 
to  60,  50  or  even  40  beats,  which  is  noticed  in  puerperal  women, 
and  which  was  first  described  by  Blot. 

Blot  asserts  that  this  phenomenon  occurs  more  frequently 
in  multipart,  and  that  it  is  an  indication  of  the  state  of  health 


DISEASES  OF  THE  VASCULAR  SYSTEM     331 

of  the  puerperal  woman,  but  that  it  is  not  on  the  other  hand 
influenced  by  the  state  of  nutrition,  the  duration  of  the  pains 
or  the  period  of  so-called  milk-fever.  He  denied,  however, 
its  causation  by  some  sort  of  exhaustion,  relying  for  this  upon 
the  well-known  sphygmographic  researches  of  Marey  who  has 
demonstrated  that  an  increase  in  the  arterial  pressure  is  accom- 
panied by  a  diminished  pulse-rate. 

With  all  due  respect  to  the  sphygmographic  results  of 
Marey  we  must  admit  that  observation  at  the  bed-side  rather 
tends  to  prove  that  the  striking  diminution  in  the  pulse-rate  is 
a  sign  of  cardiac  weakness  and  of  a  serious  decrease  in  the 
blood-pressure.  This  is  probably  the  prevalent  opinion  among 
experienced  medical  practitioners.  We  clinicians  frequently 
observe  an  analogous  slowness  of  the  pulse  after  the  crisis  of 
acute  diseases,  oftenest  in  young  people  and  even  in  children. 
We  see  in  this  a  sign  of  a  good  solemn  crisis,  but  at  the  same 
time  an  indication  of  weakness  of  the  heart  which  requires  the 
most  careful  treatment,  stimulants  and  roborants  as  well  as  the 
best  possible  nourishment  and  quiet  rest  in  bed.  But  the 
pulse  may  withal  occasionally  be  strong  and  tense,  and  we  do  not 
desire  to  lay  down  any  decision  whether  the  blood-pressure  is 
abnormally  high  or  low;  clinical  experience  is,  however,  incon- 
trovertible that  where  the  pulse  is  markedly  slow  we  must 
apprehend  conditions  of  syncope  and  collapse. 

We  should  like  to  apply  these  experiences  to  the  puerperal 
state  and  to  regard  the  slowness  of  the  pulse  as  a  sign  that  there 
occurs  in  child-bed  a  certain  weakness  of  the  activity  of  the  heart 
and  of  the  circulation  which  necessitates  a  stimulating  and  sus- 
taining procedure.  It  is  undeniable  that  such  a  cardiac  weak- 
ness must  be  of  importance  to  a  diseased  heart  and  that  it  must 
favour  collapse  on  the  part  of  it.  The  profuse  sweats  fre- 
quently seen  at  the  beginning  of  child-bed  also  speak  for  a 
certain  measure  of  debility.  Fellner1  attributes  the  decrease 
in  the  pulse-rate  to  a  diminution  and  deterioration  of  the 
quantity  of  blood  associated  with  a  relatively  too  large 
heart. 

5.    Anatomical    changes    in    the    heart,    and    espe- 

1Fellner,  Die  Bezieh.  innere  Krank.  etc. 


332 

cially  in  the  myocardium  have  been  observed  post-mortem  in 
parturient  women  comparatively  often,  even  when  death  was 
not  due  to  an  infectious  disease.  Firchow  has  pointed  out  the 
occurrence  of  fatty  and  other  degenerations  of  the  muscle  of 
the  heart  in  puerperal  women,  and  Ponfick  says  that  he  has 
seen  the  anaemic  form  of  fatty  degeneration  of  the  heart  in 
protracted  labours  especially. 

6.  Mention  must  also  be  made  that  owing  to  the  labour- 
pains  a  certain  over-exertion  may  easily  take  place  on  the 
part  of  the  heart.  Zweifel  especially  has  rightly  laid  stress  on 
this  point.  The  case  of  rupture  of  the  aorta  during  labour, 
communicated  by  Simpson,  illustrates  the  condition  sufficiently. 
The  fact  that  embolism  occurs  comparatively  often  in  labour 
also  points  to  an  increased  pressure  in  the  vascular  system.  By 
most  careful  measurements  of  the  blood  pressure  in  pregnant, 
parturient,  puerperal  and  suckling  women,  Fellner  has  demon- 
strated that  the  pressure  is  somewhat  higher  during  pregnancy, 
that  it  reaches  its  highest  point  at  the  height  of  a  labour-pain, 
falling  again  during  the  interval,  and  that  it  sinks  with  the 
rupture  of  the  membranes  in  proportion  to  the  rapidity  with 
which  the  liquor  amnii  escapes.  According  to  Fellner,  the 
highest  blood-pressure  is  observed  at  the  moment  the  head 
passes  through  the  vulva.  After  delivery,  the  blood-pressure 
falls  to  far  below  normal. 

Finally  we  must  remember  that  the  administration  of  chloro- 
form in  labour  has  a  debilitating  influence  upon  the  muscles  of 
the  heart. 

On  the  whole,  the  conditions  described  above  have  in  our 
opinion  doubtless  the  result  that  the  heart  is  in  various  ways 
endangered  during  pregnancy  and  labour.  During  pregnancy, 
and  especially  in  the  later  months,  greater  demands  are  made 
upon  its  activity;  these  demands  are  in  labour  increased  up  to 
the  point  of  over-exertion;  at  the  end  of  the  labour-act  the 
action  of  the  heart  falls  to  such  an  extent  that  even  under  normal 
circumstances  the  greatest  vigilance  on  our  part  is  required. 
Where  the  circumstances  are  normal  all  these  perturbations 
are  more  easily  withstood  or  corrected,  but  it  cannot  be  denied 
that  they  may  prove  disastrous  to  a  diseased  heart. 


DISEASES  OF  THE  VASCULAR  SYSTEM     333 

Disturbances  on  the  part  of  the  lungs  dur* 
ing  pregnancy. — On  the  part  of  the  lungs  there  also  arise 
disturbances  in  the  course  of  pregnancy.  In  the  last  months  of 
pregnancy  the  encroachment  on  the  abdominal  space  forces  the 
diaphragm  upwards  and  causes  thereby  a  diminution  in  the 
lung  volume  (retraction)  and  a  limitation  in  the  respiratory 
capacity.  It  is  clear  that  these  conditions,  first  appreciated  by 
Spiegelberg,  must  have  a  disturbing  influence  upon  the  pul- 
monary circulation  of  the  blood  and  upon  the  activity  of  the 
right  ventricle.  True,  Wintrich  and  Kiichenmeister  have 
shown  that  the  vital  capacity  of  the  lungs  is  not  diminished 
during  pregnancy,  and  similarly,  the  cyrtometric  researches 
of  Dohm  have  proved  that  the  thorax  is  not  materially  lessened 
on  account  of  the  pregnant  uterus.  Nevertheless,  an  objective 
observation  of  the  mechanical  conditions  of  respiration  is  bound 
to  give  rise  to  the  opinion  that  respiration  appears  to  be  hin- 
dered by  pregnancy,  and  that  in  spite  of  the  normal  size  of  the 
thorax  and  the  normal  capacity  of  the  lungs,  the  extent  of 
healthy  organism  is  encroached  upon,  so  that  disturbances  are 
more  likely  to  arise  from  that  quarter  in  pregnant  women  than 
in  women  who  are  not  pregnant. 

After  labour  the  state  of  affairs  suddenly  undergoes  a 
change,  the  resistance  to  the  respiration  becomes  less,  the  aspira- 
tion of  the  blood  stronger,  and  it  is  not  at  all  impossible  for 
disturbances  in  the  respiration  and  congestion  in  the  lungs  to 
arise  in  consequence,  which  only  become  pronounced  gradually, 
that  is,  in  the  first  days  of  the  puerperium. 

Changes  in  the  blood  during  pregnancy. — As 
regards  the  blood,  it  may  be  mentioned  that  plethora  or 
hydrasmia  is  still  generally  believed  to  occur  during  pregnancy, 
and  that  the  condition  is  capable  of  influencing  injuriously  the 
action  of  the  heart. 

Secretion  of  the  kidneys  during  pregnancy. — 
Not  without  importance  are  the  conditions  of  the  renal  secre- 
tion. Pregnancy  predisposes  to  a  diminution  of  the  action  of  the 
kidneys;  this  may  be  taken  to  be  generally  the  case,  although 
naturally  it  cannot  be  proved  in  every  instance.  Indeed,  preg- 
nancy predisposes  to  albuminuria,  swellings  and  oedema.  These 


334  HEALTH,  DISEASE,  MARRIAGE 

conditions  frequently  become  manifest  in  diseases  of  the  heart 
by  the  early  appearance  of  oedemata,  the  most  important  sign 
of  absence  of  compensation;  they  maintain  and  increase  the 
dyspnoea  which  often  appears  even  under  normal  circumstances, 
towards  the  end  of  pregnancy. 

If  we  take  a  general  view  of  the  above-mentioned  influences 
and  disturbances  which  are  as  a  rule  associated  with  pregnancy, 
we  find  that  as  regards  the  activity  of  the  heart,  the  circulation 
and  formation  of  the  blood,  the  respiration  and  finally,  the 
secretion  of  the  kidneys,  conditions  are  created  which  may  easily 
lead  to  disturbances  of  various  kinds.  These  disturbances  are  not 
directly  obvious;  on  the  contrary,  they  remain  within  such  limits 
that  they  are  compatible  with  a  feeling  of  perfect  health,  and 
experience  shows  that  healthy  women  bear  and  conquer  them 
easily. 

Nevertheless  we  may  say  that  the  latitude  of  health  is 
limited,  and  under  extraordinary  circumstances  it  easily  happens 
that  the  border-line  is  exceeded,  so  that  full  compensation 
cannot  be  said  to  exist. 

In  pregnant  women  who  are  no  longer  quite  healthy,  morbid 
changes  take  place  therefore  very  easily.  With  regard  to 
women  suffering  from  heart-disease  we  may  presume — and 
experience  confirms  it — that  only  the  mild  and  well-compen- 
sated cases  remain  unimpaired  in  consequence  of  pregnancy  and 
child-bed,  but  that  the  possibility  of  trouble  exists  for  all  the 
severer  cases.  We  have  seen  that  the  action  of  the  heart  is 
threatened  in  many  ways,  and  it  may  easily  happen  that  the 
border-line  of  its  capability  is  exceeded  in  cases  of  cardiac 
disease;  and  to  this  we  have  to  add  the  difficulty  of  breathing 
and  that  of  the  renal  secretion.  The  more  severe  the  heart 
disease,  the  sooner  consequences  will  ensue  which  may  prove 
for  the  woman  dangerous  and  calamitous. 

Although  these  dangers  begin  with  the  commencement  of 
pregnancy  they  appear  at  first  imperceptibly,  and  attain  as  a 
rule  a  considerable  degree  in  the  second  half  of  the  term.  But 
there  are  not  wanting  cases,  though  they  are  rare,  in  which 
decided  signs  of  absence  of  compensation  make  their  appearance 
in  women  suffering  from  heart-disease  in  the  very  first  months 


DISEASES  OF  THE  VASCULAR  SYSTEM     335 

of  pregnancy.  These  disturbances  may  disappear  and  be  com- 
pensated for ;  as  a  rule,  however,  they  grow  with  inconsiderable 
fluctuations  from  day  to  day  and  bring  the  patients  into  a  most 
distressing  condition  which  makes  the  greatest  demands  upon 
their  physical  and  moral  ability  to  endure  suffering.  The 
dyspnoea  and  oedema  vary,  the  increasing  tumefaction  renders 
the  patients  helpless,  unable  to  do  any  work,  and  almost  unable 
to  move  about.  The  appetite  is  disturbed,  and  attacks 
of  dyspnoea,  particularly  during  the  night,  make  sleep 
impossible. 

Labour. — Nevertheless,  experience  teaches  that  all  these 
complaints  which  grow  from  day  to  day  can  usually  be  endured 
until  the  end  of  pregnancy.  The  termination  of  the  distressing 
period  is  anxiously  awaited  both  by  doctor  and  patient,  and  the 
commencement  of  labour-pain  is  joyfully  welcomed.  The  pains 
of  labour  are  cheerfully  gone  through  since  they  bring  release 
from  extreme  anguish ;  but  with  the  end  of  the  labour-act,  with 
the  liberation  from  suffering,  with  the  desired  calm,  there  enters 
also  a  condition  of  weakness,  a  collapse,  which  harbours  new 
dangers  and  which  not  infrequently  leads  to  a  development  of 
oedema  of  the  lungs.  If  this  immediate  danger  is  surmounted, 
there  still  remains  a  perilous  state  of  cardiac  debility,  there  is 
still  a  possibility  that  paralysis  of  the  heart  may  supervene,  and 
it  is  only  by  very  careful  nursing  and  slowly  that  this  painful 
condition  can  be  overcome.  Often  enough  the  heart  continues 
weak  for  a  long  time,  and  compensation  is  disturbed  for  a 
lengthy  period,  sometimes  unfortunately  for  good. 

The  state  of  these  puerperal  women  shortly  after  labour 
has  some  resemblance  to  that  after  the  crisis  of  acute  diseases. 
We  have  already  made  this  comparison  when  speaking  of  the 
slowness  of  the  pulse  in  child-bed,  and  we  consider  it  necessary 
to  devote  a  few  more  words  to  this  point.  Pregnancy,  a 
normal  physiological  process,  occasions  especially  towards  the 
end  so  many  disturbances  and  such  a  limitation  in  the  normal 
latitude  of  health,  that  it  may  almost  be  regarded  as  a  morbid 
condition.  Its  signification  is  not  far  removed  from  that  of  an 
illness  and  it  requires  just  as  careful  treatment  as  an  acute 
disease. 


336  HEALTH,  DISEASE,  MARRIAGE 

This  comparison  with  the  condition  after  the  crisis  of  acute 
diseases  receives  further  justification  from  the  fact  that  preg- 
nancy is  succeeded,  during  child-bed  and  later  as  well,  by  a 
number  of  complaints  which  are  analogous  to  the  sequelae  of 
acute  pyrexial  diseases.  Among  these  we  may  mention  in  par- 
ticular nervous  diseases,  such  as  encephalitis,  myelitis  and  mul- 
tiple neuritis;  further,  chorea  and  polyarthritic  rheumatoid 
affections; — a  certain  analogy  is  also  present  in  the  disease  of 
the  kidneys.  Such  an  analogy  we  might  also  find  in  the  circum- 
stance that  at  the  height  of  pregnancy  the  predisposition  to 
fresh  infectious  diseases  is  very  slight,  whilst  during  child-bed 
a  predisposition  to  purulent  infections,  erysipelas  and  severe 
tuberculous  processes  is  a  distinguishing  feature. 

Almost  all  authors  are  agreed  that  pregnancy  is  calculated 
to  produce  fresh  and  untoward  complications  in  patients  who 
suffer  from  chronic  heart-disease.  Of  course  this  indictment 
does  not  apply — or  only  exceptionally  so — to  the  more  benign 
and  perfectly  compensated  cases  of  such  affections  of  the  heart. 
These  are  so  much  like  the  normal,  healthy  state  that  they  can 
endure  the  pregnancy  quite  as  well  as  women  in  a  perfect  con- 
dition of  health  and  without  any  .particular  difficulty,  and  it  is 
conceivable,  as  Wessner  says,  that  many  such  cardiac  diseases 
can  pass  unrecognised  from  the  beginning  of  the  pregnancy  to 
the  end  of  the  puerperium  because  there  are  no  symptoms  point- 
ing to  disease  of  the  heart.  It  is  however  totally  different  with 
the  severe  forms  of  chronic  heart-disease  which  manifest  already 
signs  of  disturbed  compensation.  These  cases  undergo  an  aggra- 
vation almost  without  an  exception,  and  become  finally  more  or 
less  dangerous  to  life;  in  fact,  a  considerable  number  of  these 
patients  succumb  directly  as  a  result  of  pregnancy  and  child-bed. 
Although  there  had  already  existed  a  severe  form  of  heart- 
disease  it  is  by  no  means  justifiable  to  assume  that  a  similar 
aggravation  or  even  death  would  have  happened,  had  there 
been  no  pregnancy.  Purely  objective  observations,  as  well  as 
the  study  of  the  processes  involved,  show  sufficiently  clearly 
that  the  condition  of  women  suffering  from  such  diseases  of  the 
heart  is  considerably  worse  after  pregnancy  and  child-bed. 

Macdonald  says:  "In  all  the  cases  of  heart-disease  which 


DISEASES  OF  THE  VASCULAR  SYSTEM     337 

have  been  recorded  in  this  work1  it  will  be  observed  that  if  the 
lesion  was  at  all  severe,  the  labour  was  found  to  be  invariably 
accompanied  by  extreme  cardiac  irregularity,  with  also  a  feeble 
irregular  and  intermittent  pulse,  much  dyspnoea  and  cyanosis. 
In  a  certain  proportion  of  cases  unconsciousness  was  noticed, 
the  patients  having  the  appearance  of  persons  under  the  influence 
of  chloroform.  In  some  cases  the  perturbation  of  the  circula- 
tion was  such  as  to  end  during  the  labour,  in  sudden  "death. 
More  frequently  however,  we  notice  that  the  confinement  was 
tided  over  and  a  temporary  but  very  frequently  delusive 
improvement  succeeded  it.  Where  death  results  in  cardiac  cases 
the  post-mortem  examination  reveals  almost  invariably  pulmo- 
nary congestion,  especially  of  the  bronchial  mucous  membrane, 
and  pulmonary  oedema.  Often  also  we  find  apoplectic  extrava- 
sation of  blood  into  the  lungs  of  recent  or  of  older  date,  and 
occasionally  pneumonia,  and  very  frequently  pleuritic  effusions." 

The  experiences  also  of  other  authors  confirm  that  death 
seldom  happens  during  pregnancy ;  labour  at  term  or  premature 
labour  is  the  general  issue.  The  real  danger  begins  at  or  after 
labour.  Frequently  death  occurs  during  the  labour  act,  and 
more  frequently  still  after  its  completion.  The  most  frequent 
causes  of  sudden  death  are  oedema  of  the  lungs,  and  paralysis 
of  the  heart.  Later  as  well,  even  after  many  weeks  or  months, 
death  may  occur  in  consequence  of  a  permanent  aggravation  in 
the  compensatory  disturbances  through  dropsy,  embolism  or 
infarcts. 

Many  observers  believe  that  the  complaints  of  heart-diseased 
women  who  become  worse  through  pregnancy  are  relieved 
immediately  after  labour,  and  that  the  condition  of  the  puer- 
peral woman,  if  no  fresh  infarcts  are  formed,  is  consequently 
much  improved.  Fellner  also  shares  this  optimistic  view  of 
most  gynaecologists,  a  view  contrary  to  that  held  by  internal- 
medicine-clinicians.  This  is  the  result  of  the  difference  in  the 
material  observed  by  the  two  classes  of  physicians,  a  difference 
about  which  we  shall  again  have  something  to  say.  The  feeling 
of  relief  is  certainly  striking,  and  the  knowledge  that  an  exacting 


bearings  of  chronic  disease  of  the  heart  upon  pregnancy,  parturition 
and  child-bed,  by  Angus  Macdonald.   London,  1878,  p.  201. 


338  HEALTH,  DISEASE,  MARRIAGE 

task  is  done  with,  inspires  the  poor  patient  with  renewed  hope. 
But  the  condition  is  nevertheless  still  dangerous,  and  the  longed- 
for  quick  improvement  often  never  comes. 

Interruption  of  pregnancy. —  Immediately  after 
the  confinement  there  ensues,  as  already  mentioned,  a  state  of 
weakness,  a  more  or  less  marked  collapse,  which  can  only  slowly 
be  overcome.  The  cause  is  plainly  visible.  The  over-exertion 
of  the  heart  during  labour,  the  disordered  compensation,  contin- 
ues undiminished  after  the  labour  is  over,  and,  moreover,  the 
psychical  condition,  the  moral  fatigue  must  also  not  be  forgotten. 
Through  the  long  continued  period  of  suffering,  growing  worse 
day  by  day  during  the  later  part  of  the  pregnancy,  through 
the  weary  time  of  anxious  waiting  for  the  unknown  end  to  come, 
the  moral  resistibility  is  exhausted,  and  the  period  of  excitement 
is  succeeded  by  one  of  tiresomeness  which  contributes  to  the 
general  state  of  collapse. 

Having  now  pointed  out  the  dangers  which  confront  women 
suffering  from  affections  of  the  heart  during  pregnancy  and 
child-bed,  we  must  turn  our  attention  next  to  the  important 
practical  question :  what  are  the  ways  and  means  to  be  adopted 
in  order  to  avert  or  diminish  these  dangers? 

Macdonald  has  accurately  described  the  duty  of  the  medical 
man  in  such  cases  when  he  said:  "It  is  certainly  devoutly  to  be 
wished  for  that  if  possible — given  that  one  of  our  patients  is 
the  victim  of  a  special  cardiac  lesion — we  should  be  able  to 
predict  what  are  the  special  additional  risks,  if  any,  to  which 
the  pregnant  parturient  and  lying-in  conditions  expose  her,  and 
what  are  the  prophylactic  or  therapeutic  measures  we  are  bound 
to  adopt  so  as,  if  practicable,  to  avoid  or  diminish  such  risks." 
(P.  4.  1.  c.) 

If  a  pregnant  woman  affected  with  heart-disease  begins  to 
manifest  signs  of  absence  of  compensation  the  most  careful  and 
suitable  treatment  must  be  instituted  to  re-establish  compensa- 
tion and  to  maintain  it  so  re-established.  This  task  does  not 
consist  merely  in  telling  the  patients  to  drink  plenty  of  milk  and 
in  prescribing  for  them  digitalis,  but  it  is  not  possible  to  enumer- 
ate here  all  the  necessary  details. 

The  question  which  concerns  us  most  is  whether  the  normal 


DISEASES  OF  THE  FASCULAR  SYSTEM     339 

end  of  the  pregnancy  should  be  awaited  or  whether  and  under 
what  special  circumstances  artificial  premature  labour  may  or 
should  be  induced?  The  whole  discussion  turns  round  this 
question. 

It  is  well  to  make  the  preliminary  observation  that  in  women 
with  heart  disease  miscarriage  occurs  comparatively  often;  it 
almost  appears  as  if  this  were  nature's  attempt  to  effect  a  cure. 

Artificial  premature  labour. — The  first  to  recom- 
mend the  induction  of  artificial  labour  was  Da  Costa  who  in 
1827  saw  an  immediate  improvement  after  a  spontaneous  prem- 
ature labour  in  the  8th  month  in  a  case  where  an  aneurysm  of 
the  heart  which  had  existed  for  some  time  underwent  a  con- 
siderable change  for  the  worse  during  pregnancy.  Later,  Hof- 
mann  (Neue  Zeitschrift  fur  Gyn.  XIV.,  p.  386)  simply  accepted 
this  proposal  of  Da  Costa  despite  its  vagueness.  As  a  matter 
of  fact,  the  operation  has  several  times  been  performed  on 
account  of  "heart-affections."  Most  gynaecologists  have  given 
utterance  to  their  opinions  on  the  point,  but  the  indication  for 
artificial  premature  labour  has  been  recognised  in  a  very  limited 
degree  only. 

Even  Macdonald  who  shows  a  deep  medical  understanding 
of  the  enormous  importance  of  the  complication  in  question 
expresses  himself  thus:  "Premature  labour  should  seldom  or 
never  be  recommended,  because  it  is  so  much  more  likely  to  do 
greater  harm  by  disturbing  the  action  of  the  heart  and  the  con- 
dition of  the  lungs  than  any  good  it  might  produce  by  termina- 
ting the  evil  effects  of  the  pregnancy.  It  is  always  to  be  remem- 
bered that  relief  of  symptoms  is  not  certain  after  delivery  or 
anything  like  certain.  The  only  conditions  which  seem  to 
warrant  the  induction  of  premature  labour,  are  the  presence 
of  influences,  which  unduly  distend  the  abdomen  and  thus  keep 
the  diaphragm  in  a  state  of  continuous  elevation."  (P.  206,  I.e.) 
Macdonald  is  therefore  opposed  to  premature  labour  not  on 
its  account,  but  on  account  of  the  dangers  which  accompany  it. 
He  confines  himself  to  recommending  that  women  and  girls 
suffering  from  heart  disease  should  not  be  permitted  to  marry 
(an  advice  which  is  seldom  accepted),  that  they  should  during 
pregnancy  be  treated  and  nursed  most  carefully,  and  that  labour 


340 

should  when  it  does  arrive  be  expedited  and  facilitated  as  far 
as  possible  by  the  use  of  forceps  and  chloroform. 

Spiegelberg  thinks  that  artificial  premature  labour  is  per- 
missible in  cases  of  aortic  defects,  and  justified,  even  necessary, 
in  mitral  lesions  under  certain  circumstances.  According  to 
Lohlein  the  indication  for  premature  labour  is  present  in  both 
kinds  of  heart-disease  in  the  same  manner:  (a)  if  unfavourable 
conditions  have  developed  entirely  or  partially  in  consequence  of 
the  pressure  of  the  uterus  or  of  the  upward  pushing  of  the  dia- 
phragm into  the  thoracic  cavity;  (b)  if  the  death  of  the  mother 
is  shortly  expected  (in  such  a  case,  however,  the  premature 
labour  is  likely  to  come  too  late) . 

Schleyer  says  with  regard  to  artificial  premature  labour, 
that  it  ought  to  be  restricted  to  rare  cases  only.  Sometimes  it 
is  necessary  to  have  recourse  to  it,  but  seeing  that  the  results 
have  so  far  not  been  very  satisfactory  it  is  advisable  to  admit  the 
indication  as  sparingly  as  possible.  Dohrn  thought  that  as  a 
matter  of  principle  we  should  adhere  to  an  expectant  attitude. 

On  the  whole  it  may  therefore  be  said  that  modern  gynaecol- 
ogists recognise  the  indication  for  artificial  premature  labour 
in  complications  of  pregnancy  with  chronic  heart  disease,  but 
only  to  a  limited  extent. 

There  are  two  reasons  why  opinion  of  the  indication  of  arti- 
ficial premature  labour  is  so  reserved:  i.  the  dangers  which  the 
operation  presents  for  both  mother  and  child ;  2.  the  undervalua- 
tion of  the  dangers  which  pregnancy  involves  in  women  with 
chronic  heart  disease.  In  point  of  fact,  we  think  that  these  dan- 
gers are  underrated  by  most  authors,  and  that  one  of  the  princi- 
pal causes  of  this  under-estimation  is  the  dissertation  by  Wessner. 
This  author  attributes  to  the  complication  only  a  slight  injurious 
influence.  "The  cause  of  the  unfavourable  influence  of  preg- 
nancy on  the  affection  of  the  heart  does  not  lie  so  much  in  either 
the  increased  activity  of  the  organ  resulting  from  the  pregnancy, 
or  the  sudden  fluctuations  in  the  blood-pressure  occasioned  by 
the  labour  act,  or  in  the  high  position  of  the  diaphragm,  as  in 
the  psychical  and  physical  over-exertions  of  the  labour  process 
which  have  a  reacting  influence  upon  the  heart.  But  statistics 
show  that  by  far  the  greatest  number  of  cases  withstand  these 


DISEASES  OF  THE  VASCULAR  SYSTEM     341 

over-exertions  without  any  particular  injury.  It  rarely  happens 
that  a  cardiac  defect  succumbs  to  pregnancy  or  labour  as  such; 
as  a  rule  it  is  severe  forms  of  heart  disease  which  we  then  have 
before  us,  and  secondly  complications."  Wessner  concludes 
therefore  that  the  prognosis  (in  complications  of  chronic  heart 
disease  with  pregnancy)  is  for  both  mother  and  child  consider- 
ably better  than  it  is  generally  believed  to  be,  and  that  the  induc- 
tion of  premature  labour  does  not  appear  to  be  justified.  Fellner 
in  his  latest  work  expresses  the  same  opinion. 

As  we  have  already  mentioned,  we  cannot  at  all  agree  with 
these  views  and  conclusions  arrived  at  in  virtue  of  the  apparently 
favourable  statistics  of  the  gynaecological  clinics.  That  these 
statistics  appear  favourable  is  to  a  great  extent  due  to  the  differ- 
ent character  of  the  material.  Pregnant  women  with  heart 
disease  seek  as  a  rule  admission  into  gynaecological  clinics 
shortly  before  their  expected  confinement,  that  is,  at  a  time, 
when  the  natural  termination  of  the  pregnancy,  even  where 
there  are  fairly  severe  disturbances  already  present,  is  not  likely 
to  be  long  delayed.  Under  such  circumstances  it  is  only  natural 
that  if  at  all  possible  the  induction  of  premature  labour  should 
be  avoided,  considering  that  notwithstading  recent  improve- 
ments the  operation  is  still  a  rather  serious  one.  On  the  other 
hand  women  with  heart  disease  who  are  pregnant  come  under 
the  observation  of  the  internal  clinician  on  account  of  their 
disease,  and  the  latter  demands  the  earliest  possible  arti- 
ficial delivery  if  the  illness  can  no  longer  be  combated  by 
the  usual  therapeutic  agencies.  We  must  also  return  once 
more  to  the  other  point  upon  which  Wessner  relies  in  his 
assertions,  namely  that  a  large  number  of  cardiac  affections 
are  overlooked  in  pregnant  women  because  they  do  not 
make  themselves  apparent  by  any  symptoms  or  disturbances. 
This  fact  is  perfectly  true,  but  it  must  not  be  taken  into 
account  with  regard  to  our  subject  and  with  regard  to  the 
question  of  artificial  premature  labour,  because  it  is  only  such 
cases  of  heart  disease  which  come  into  consideration  at  all,  that 
have  already  led  to  disturbances  of  compensation. 

That  heart  disease,  and  especially  valvular  lesions,  may 
exist  without  markedly  affecting  the  whole  organism  is  a  fact 


342  HEALTH,  DISEASE,  MARRIAGE 

well  enough  known;  it  is  just  what  happens  in  the  mild  cases 
with  full  compensation.  Such  patients  experience  no  troubles, 
they  feel  perfectly  well,  can  work,  move  about  and  live  like  peo- 
ple whose  health  is  unimpaired.  Analogous  is  the  behaviour  of 
pregnancy  towards  the  cardiac  defect.  In  mild,  fully  compen- 
sated cases  pregnancy  is  endured  quite  as  easily  as  by  women 
who  are  in  perfect  health,  and  there  is  no  reason  to  interfere 
with  them.  The  normal  course  of  pregnancy  and  parturition 
is  as  a  rule  not  interrupted.  But  experience  teaches  that  with 
repeated  pregnancies  injury  supervenes  in  time  and  that  a  more 
or  less  severe  and  lasting  defect  of  compensation  arises  in 
consequence. 

Totally  different  is  the  behaviour  of  the  severe  cases  of 
heart  disease  which  no  longer  possess  an  undisturbed  compensa- 
tion. When  such  women  become  pregnant  the  signs  of  the 
absence  of  compensation  increase  in  severity  and  assume  in  the 
latter  months  of  the  utero-gestation  unendurable  proportions. 
Here  the  pregnancy  is  undoubtedly  injurious,  in  other  words, 
the  destruction  of  compensation  increases,  and  the  most  careful 
treatment  is  frequently  unable  to  re-establish  it.  It  will  now 
be  the  duty  of  the  physician  to  form  an  opinion  whether  the 
patient  will  be  able  to  withstand  the  burden  and  suffering  till 
the  natural  commencement  of  the  labour-pains,  or  whether  the 
defect  of  compensation  will  grow  to  such  a  degree  that  death 
will  most  probably  result. 

If  some  authors  say  that  the  life  of  the  mother  must  be  in 
absolute  danger  we  cannot  take  this  to  mean  that  this  danger 
must  be  an  immediate  one  (since  the  life-saving  interference 
would  then  arrive  too  late)  but  that  it  must  be  anticipated  with 
certainty  or  with  the  greatest  probability.  We  cannot  decide 
this  literally  but  every  experienced  conscientious  and  observant 
practitioner  must  be  able  to  come  to  a  decisive  conclusion. 
Statistics  of  internal  clinicians  show  that  of  severe  cases  of 
chronic  heart-disease  nearly  40%  die  in  consequence  of  preg- 
nancy and  parturition.  This  figure  is  big  enough  to  warrant 
us  in  saying  that  in  every  pregnant  woman  suffering  from  heart- 
disease  in  whom  defects  of  compensation  exist  and  are  on  the 
increase,  the  indication  of  artificial  premature  labour  is  quite 


DISEASES  OF  THE  VASCULAR  SYSTEM     343 

justified.  The  life  of  the  child  which  is,  by  the  way,  always  in 
danger  even  where  the  pregnancy  of  women  with  heart  disease 
follows  a  normal  course  is  of  no  consequence  in  comparison 
with  that  of  the  mother;  surely  the  latter  or  her  husband  has  a 
perfect  right  to  renounce  the  happiness  of  having  children  if 
by  an  artificial  interruption  of  the  pregnancy  the  life  of  the 
pregnant  woman  can  be  saved  or  prolonged. 

We  are  of  the  opinion  that  in  all  cases  of  pregnancy  com- 
plicated with  heart-disease  in  which  an  absence  of  compensation 
occurs,  that  keeps  increasing  in  spite  of  careful  treatment  and 
is  likely  to  attain  serious  proportions,  the  interruption  of  the 
pregnancy  is  indicated  and  justified.  If  threatening  symptoms 
appear  already  in  the  first  half  of  the  pregnancy,  artificial  abor- 
tion takes  the  place  of  artificial  premature  labour.  The  practi- 
tioner will  doubtless  prefer  the  former  seeing  that  it  is  an 
easier  operation  and  one  which  can  be  finished  more  quickly. 

As  regards  now  the  dangers  to  which  artificial  premature 
labour  exposes  mother  and  child,  we  must  admit  that  in  accord- 
ance with  the  opinion  of  gynaecologists  we  have  not  in  recent 
years  made  much  progress  in  this  respect.  Rossi's  method 
seemed  at  first  to  promise  a  great  deal,  but  on  careful  examina- 
tion it  has  been  found  that  the  old  methods  which  have  stood 
the  test  of  time  are  after  all  preferable.  (v.  Bardeleben.)1 
And  as  far  as  the  weariness  is  concerned  which  is  associated  with 
the  long  duration  of  an  artificial  premature  labour,  we  are  not 
disposed  to  attach  very  great  importance  to  it,  since  parturient 
women  who  have  suffered  considerably  are  as  a  rule  not  very 
sensitive,  and  because  they  are  quite  prepared  to  endure  a  fresh 
ordeal  in  the  hope  that  it  will  mean  the  end  of  their  troubles. 
On  the  other  hand  we  desire  to  point  out  that  the  gain  of  a 
few  weeks  in  such  a  distressing  condition  as  pregnant  women 
with  heart  disease  have  to  endure,  is  an  enormous  advantage, 
considering  that  the  continuation  and  aggravation  of  the  distress 
for  several  weeks  longer  exhausts  the  physical  and  moral 
strength  of  the  patients  to  such  an  extent  that  after  the  confine- 
ment they  break  down  completely  in  body  and  soul. 


V  Bardeleben,  Wesen  u.  Wert  der  schnellen  mechan.-instrum.     Mutter- 
mundserw.  etc.  Arch.  f.  Gyn.  Vol.  40,  No.  i. 


344  HEALTH,  DISEASE,  MARRIAGE 

It  is  not  feasible  to  lay  down  special  rules  with  regard  to 
the  different  forms  of  valvular  disease  or  to  formulate  different 
indications  respecting  marriage  according  to  the  seat  of  the 
lesion.  Statistics  show  that  most  deaths  occur  during  pregnancy 
complicated  with  mitral  stenosis.  But  the  reason  is  mainly 
because  mitral  affections  are  altogether  the  most  frequent  val- 
vular lesions  in  the  female  sex.  What  must  influence  our  opin- 
ion decisively  is  the  question:  Is  there  an  incompetence  of  the 
muscle  of  the  heart  or  not?  Many  women  with  well  compen- 
sated valvular  defects  tide  over  repeated  pregnancies  without 
developing  any  disturbance  in  the  compensation.  We  agree 
with  Fellner  in  holding  the  prohibition  of  marriage  in  well- 
compensated  cases  of  heart  disease  unjustified  and  harsh. 

Prohibition  of  marriage. — Having  in  the  above 
remarks  discussed  the  attitude  to  be  taken  up  by  the  physician 
in  the  presence  of  pregnancy  complicated  with  heart  disease, 
we  must  now  devote  a  few  words  to  those  cases  where  we  are 
compelled  at  an  earlier  stage  to  put  in  a  word  of  advice.  We 
refer  to  women  suffering  from  cardiac  affections  whom  it  is  our 
duty  either  to  dissuade  from  marrying  or  if  they  are  already 
married  to  warn  against  allowing  themselves  to  become  preg- 
nant. It  is  only  in  the  severest  cases  that  the  physician  is  called 
upon  to  oppose  a  marriage  with  all  possible  energy.  Just 
because  we  can  only  advise  we  must  always  remember  that  as  a 
rule  our  orders  are  not  carried  out  if  they  involve  as  in  this  case 
sorrow  and  disappointment.  It  is  therefore  necessary  that  we 
should  bear  in  mind  that  our  warning  words  may,  if  not 
accepted,  cause  more  mischief  than  good  because  to  the  real 
danger  occasioned  by  the  disease  an  aggravating  element  would 
be  added  by  the  fear  and  worry  of  the  patients  who  have  possi- 
bly been  hitherto  ignorant  of  their  condition  and  of  its  serious 
character.  Besides,  considering  that  in  the  majority  of  cases 
we  should  be  against  the  marriage  of  women  affected  with 
heart  disease  on  account  of  the  dangers  which  we  anticipate 
from  a  possible  pregnancy,  we  can  avoid  the  infliction  of 
anguish  upon  our  patients  by  permitting  the  marriage  and  by 
instructing  the  husband  to  avoid  conception  for  as  long  as 
possible. 


DISEASES  OF  THE  FASCULAR  SYSTEM     345 

Prohibition  of  pregnancy. — Finally  we  must  remem- 
ber that  an  absolute  prohibition  of  pregnancy  will  only  very 
rarely  be  listened  to;  women  do  not  like  the  idea  of  renouncing 
maternity  altogether*  But  when  a  child  has  been  born  and  the 
family  is  not  without  an  heir,  the  physician  may  expect  that  his 
advice  to  avoid  further  pregnancies  will  be  adopted,  especially 
if  the  mother  has  become  aware  that  her  condition  has  deterio- 
rated in  consequence  of  the  first  pregnancy.  We  know  that  a 
complete  renunciation  of  all  maternal  happiness  is  to  many  a 
sore  disappointment,  and  this  is,  particularly  in  women  with 
heart  disease,  likely  to  be  as  severe  or  a  severer  trial  than  a  single 
pregnancy  which  under  advantageous  circumstances  may  pos- 
sibly take  a  favourable  course. 

It  is  our  principal  concern  in  every  case  to  study  the  pros 
and  cons  most  carefully  and  to  remember  that  thcpgh  we  must 
not  exhibit  a  want  of  energy  we  must  at  the  same  time  endeavour 
not  to  deprive  our  patients  of  every  joy  of  life. 

3.     Diseases  of  the  Myocardium. 

We  will  now  consider  the  diseases  of*he  muscles  of  the 
heart  and  their  relationship  to  marriage. 

Weakness  of  the  heart  after  infectious 
diseases. — In  the  previous  chapter  we  have  mentioned  that 
in  the  course  of  many  infectious  diseases  the  settlement  of 
bacteria  on  the  endocardium  is  the  cause  of  the  heart  disease; 
and  now  we  wish  to  point  out  that  some  infectious  diseases 
injure  the  muscular  wall  of  the  heart  itself  through  the  action 
of  the  toxins.  Diphtheria,  influenza,  more  rarely  typhus  and 
other  infectious  diseases  are  capable  of  giving  rise  to  curable 
but  nevertheless  prolonged  weakness  of  the  heart.  The  pres- 
ence of  minute  myocarditic  deposits  demonstrated  some  time 
ago  by  one  of  us  (v.  Ley  den)  in  such  cases  does  not  suffice  for 
its  explanation,  and  we  are  obliged  to  assume  that  it  is  caused 
by  toxic  action.  This  toxic  myocarditis — for  we  must  look 
upon  the  disease  as  one  analogous  to  toxic  neuritis — is  as  a  rule 
demonstrable  only  during  the  attacks  of  weakness  of  the  heart 
and  is  even  then  frequently  confused  with  purely  nervous  con- 


346  HEALTH,  DISEASE,  MARRIAGE 

ditions.  This  weakness  of  the  heart  manifests  itself  either  by 
acute  conditions  of  cardiac  collapse  with  syncope  and  a  small 
slow  pulse,  or  by  stenocardiac  attacks  with  a  quick  irregular 
pulse,  while  in  the  intervals  between  the  attacks  there  are  abso- 
lutely no  changes  demonstrable  in  the  heart.  If  we  are  there- 
fore entitled  to  admit  the  existence  of  such  a  toxic  myocarditis, 
we  must  exercise  our  medical  authority  towards  obtaining  the 
postponement  of  any  projected  marriage  until  the  last  signs  of 
the  intoxication  have  disappeared.  In  the  case  of  married 
persons,  sexual  intercourse  must  be  restricted  as  far  as  prac- 
ticable with  a  view  to  preventing  the  occurrence  of  pregnancies. 
Considering  that  the  prognosis  is  on  the  whole  favourable, 
and  that  it  is  therefore  necessary  to  impose  a  temporary  absti- 
nence only,  our  advice  will  as  a  rule  be  followed. 

Exophthalmic  goitre. — As  this  disease  also  rests 
upon  a  chronic  and  toxic  action  on  the  heart  we  will  devote  to 
it  a  few  words. 

According  to  Mobius,  "the  victims  of  exophthalmic  goitre 
suffer  and  die  on  account  of  their  hearts.  The  question  of  com- 
parative cure  is  decided  by  the  state  of  the  heart."  The  toxin 
of  Graves' s  disease  acts  therefore  mostly  on  the  heart  and  the 
blood-vessels.  Where  the  affection  is  well-marked  the  subject 
of  marriage  is  hardly  likely  to  arise  as  the  symptoms  cause  such 
a  disfigurement  that  the  existence  of  the  disease  is  plainly  visible, 
and  the  condition  of  the  patients  is  just  as  much  a  real  obstacle 
against  their  marriage  as  is  that  of  sufferers,  f.  i.  from  well- 
marked  skoliosis,  who  do  not  on  account  of  their  deformity 
marry  as  easily  as  normal  individuals.  Although  the  cause  of 
the  disease  is  now  after  many  years  of  useless  theoretical  wrang- 
ling rightly  attributed  to  a  dystrophy  of  the  thyroid  gland,  we 
are  still  no  wiser  with  regard  to  its  special  etiology.  Compara- 
tively often  there  appears  during  pregnancy  a  bronchocele  which 
disappears  at  the  end  of  the  term  of  gestation;  sometimes  it 
remains  stationary,  and  sometimes  it  returns  with  repeated  preg- 
nancies. Exophthalmic  goitre  does  not  commence  during  preg- 
nancy any  more  frequently  than  it  develops  from  a  bronchocele 
without  clinical  manifestations. 

Where  there  is  pronounced  tachycardia  pregnancy  is  natu- 


DISEASES  OF  THE  VASCULAR  SYSTEM     347 

rally  bound  to  weaken  the  organism  further  still.  A  curing 
influence  such  as  was  described  by  Charcot  may  possibly  be 
explained  after  the  analogy  of  other  examples  in  pathology.  A 
chronic  condition  becomes  acute  and  returns  to  the  normal  after 
the  acute  stage  has  run  its  course.  The  observation  of  Charcot 
of  a  disappearance  of  Graves' s  disease  has  however  until  now 
remained  the  only  one  known  in  literature.  The  complete  dis- 
appearance at  the  end  of  pregnancy  of  bronchoceles  which  had 
existed  previously  has  been  observed  more  frequently.  Van  /' 
Hoff  describes  a  case  in  which  the  pulse-rate  diminished  con- 
siderably in  the  lying-in  period,  but  went  up  again  shortly  after- 
wards. There  had  been  a  premature  labour  of  an  unripe 
embryo.  On  the  other  hand  Jeojfroy  has  seen  a  material  aggra- 
vation of  the  clinical  picture.  In  any  case,  the  prohibition  of 
pregnancy  will  have  to  be  insisted  on  if  a  previous  gestation 
was  the  cause  of  a  visible  aggravation  of  the  condition. 

Graves' 's  disease  attacks  by  far  more  women  than  men,  and 
for  this  reason  the  complication  with  pregnancy  is  of  the  great- 
est interest  to  us.  That  trouble  and  sorrow  during  the  married 
state  are  in  such  an  illness  as  exophthalmic  goitre  which  depends 
to  a  great  extent  upon  psychical  emotion,  bound  to  exercise  a 
very  great  influence  is  quite  evident.  The  husband  who  suffers 
from  this  affection  will  naturally  receive  much  injury  from 
pecuniary  and  business  worries.  Sexual  intercourse  affects  the 
patients,  where  cardiac  symptoms  are  prominent,  quite  as  much 
as  if  they  were  suffering  from  heart-disease  proper.  Consider- 
ing that  the  malady  is  easily  inherited  marriage  should  be 
avoided  if  possible. 

Nicotine  and  alcohol. — Of  other  toxic  effects  on  the 
heart  we  have  to  consider  those  of  nicotine  and  alcohol;  both 
damage  the  muscles  of  the  heart  in  different  ways.  The  con- 
sequences of  the  action  of  nicotine  manifest  themselves  mostly 
by  a  disturbance  in  the  function  of  the  heart-muscle  which  dis- 
appears gradually  after  the  cessation  of  the  abuse  of  tobacco. 
These  cases  are  therefore  of  little  import  as  regards  our  theme, 
seeing  that  we  can  as  a  rule  help  our  patients  by  recommending 
them  to  give  up  smoking.  It  is  different  as  regards  alcohol. 
Here  we  have  to  decide  whether  or  not  the  injury  caused  to 


348  HEALTH,  DISEASE,  MARRIAGE 

the  heart  by  the  abuse  of  alcohol  has  gone  so  far  that  it  will 
not  be  removed  by  the  discontinuance  of  the  pernicious  habit. 
With  regard  to  the  slight  cases  we  may  say  the  same  as  we  said 
with  regard  to  chronic  nicotine  intoxication ;  the  complaints  may 
cease  as  soon  as  the  toxic  action  of  the  alcohol  has  disappeared. 
In  this  connection  we  may  mention  that  a  prudent  marriage 
often  acts  as  an  inducement  to  restrict  the  deleterious  indulgence 
in  tobacco  and  alcohol,  and  that  from  this  prophylactic  point 
of  view  the  married  state  is  of  considerable  advantage  to  the 
health  of  these  individuals. 

Chronic  myocarditis. — But  where  the  over-indulgence 
in  alcohol  is  continued,  a  genuine  myocarditis  develops  with 
anatomical  changes  in  the  heart-muscle  or  in  the  kidneys  which 
are  .incapable  of  restitution.  Frequently  there  arises  in  associa- 
tion with  this  condition  a  chronic  form  of  alcoholic  nephritis, 
with  a  group  of  symptoms  which  resemble  closely  those  of 
cirrhosis  of  the  kidney.  Following  upon  attacks  of  cardiac 
asthma  which  become  more  and  more  frequent  and  serious  there 
appear  finally  symptoms  of  congestion  which  lead  under  dysp- 
noea and  dropsy  to  a  fatal  issue  through  the  complete  incompe- 
tence of  the  myocardium.  Should  it  happen  that  we  have  before 
us  patients  with  such  chronic  myocarditis,  an  affection  which  is, 
by  the  way,  observed  as  a  rule  in  people  of  an  advanced  age 
only,  it  will  be  our  duty  to  dissuade  them  from  marriage,  be 
they  males  or  females.  As  to  recommending  the  avoidance  of 
pregnancies,  we  shall  probably  seldom  be  in  the  position  of 
having  to  do  so,  since  conception  is  likely  under  the  circum- 
stances to  take  place  in  very  few  women,  seeing  that  in  the 
majority  of  cases  metritic  changes  exist  which  have  been  pro- 
duced by  the  general  congestion. 

We  shall  return  in  the  chapter  on  asterio-sclerosis  to  the 
special  arterio-sclerotic  affections  of  the  myocardium. 

Syphilis. — Syphilis  does  occasionally  give  rise  to  well- 
marked  myocarditis,  in  addition  to  the  injuries  to  the  muscle  of 
the  heart  occasioned  in  syphilitic  affections  through  the  endar- 
teritis  of  the  coronary  arteries,  which  injuries  are  no  different 
than  those  of  ordinary  arterio-sclerosis.  At  the  beginning  of 
the  illness,  antisyphilitic  treatment  may  often  prove  successful, 


DISEASES  OF  THE  VASCULAR  SYSTEM     349 

or  at  least  sufficiently  so  to  arrest  the  progress  of  the  disease. 
As  to  the  very  severe  cases,  the  same  rules  apply  which  we  laid 
down  for  chronic  myocarditis  generally. 

Fatty  degeneration  of  the  heart. —  Of  especial 
importance  to  our  subject  are  further  the  cases  of  "fatty  heart." 
By  this  term  we  understand  the  disturbances  in  the  activity  of  the 
heart,  which  frequently  occur  in  obese  people  without  any  real 
disease  of  the  myocardium,  but  in  whom  there  arises  in  the 
further  course  of  the  affection,  in  consequence  of  the  prolonged 
greater  strain  on  the  heart,  hypertrophy  and  dilatation  of  the 
organ,  so  that  the  deposit  of  fat  on  the  heart-muscle  is  only  of 
secondary  importance.  To  these  patients  particularly  we  are 
as  a  rule  able  to  do  good  by  instituting  the  proper  treatment 
which  consists  above  all  of  a  careful  dietetic  system  in  combi- 
nation with  physical  exercise,  and  this  good  we  can  achieve 
even  in  those  cases  where  the  subjective  complaints  are  already 
relatively  very  considerable.  Generally  speaking,  it  will  not 
be  necessary  in  such  cases  to  dissuade  from  marriage.  On  the 
contrary  marriage  may  reasonably  be  expected  in  the  case  of 
many  "luxurious  livers"  to  be  of  decided  benefit,  seeing  that  it 
may  possibly  occasion  an  alteration  in  their  mode  of  life  and 
especially  in  their  dietetic  indiscretions. 

Overexertion.  —  In  the  presence  of  disturbances  in  the 
activity  of  the  heart-muscle  which  we  observe  sometimes  f.  i. 
after  physical  over-exertion,  our  attitude  must  depend  upon 
whether  we  may  expect  a  restoration  of  the  function  on  the  dis- 
appearance of  the  injurious  influence,  or  not. 

Incompetence  of  the  heart-muscle. — In  very 
severe  cases  of  insufficiency  of  the  myocardium  it  is  immaterial 
for  our  decision  on  what  basis  they  rest.  Whether  there  exists 
a  degeneration  of  the  muscular  wall  of  the  heart  which  pro- 
duces the  cardiac  debility,  whether  we  have  before  us  a  heart 
which  has  become  incompetent  in  a  case  of  scoliosis,  whether 
it  is  the  heart  of  an  alcoholic  subject  which  begins  to  fail,  or  the 
heart  of  a  nephritic  patient  which  has  come  to  the  end  of  its 
working  capacity,  is  of  no  consequence  as  far  as  our  present 
purpose  is  concerned,  because  the  arrangements  to  be  made  are 
in  every  instance  alike;  they  vary  according  to  the  severity  of 


350  HEALTH,  DISEASE,  MARRIAGE 

the  case  between  prohibition  of  marriage,  prohibition  of  sexual 
intercourse  and  induction  of  premature  labour. 

The  neuroses  of  the  heart  we  will  consider  in  conjunction 
with  true  angina  pectoris  in  the  section  on  diseases  of  the 
arteries. 

The  sexual  intercourse  of  married  individ- 
uals affected  with  heart  disease. — Although  the  sub- 
ject of  sexual  intercourse  during  married  life  is  treated  in 
detail  in  another  chapter  of  this  work,  we  cannot  quite  avoid 
making  a  few  remarks  in  that  direction  bearing  upon  our  theme. 
That  a  considerable  alteration  takes  place  in  the  blood-vascular 
system  as  a  result  of  the  sexual  act  is  well-known  and  also 
proved.  (Mendelsohn.}  In  man  it  is  particularly  necessary 
in  this  respect  to  decide  each  case  on  its  merits.  In  very  many 
individuals  marriage  does  not  perhaps  occasion  any  difference 
in  the  mode  of  their  sexual  life,  but  in  others,  who  as  bachelors 
were  inclined  to  venereal  excesses  a  well-regulated  married 
state  usually  means  a  greatly  improved  state  of  affairs.  On  the 
other  hand,  married  men  have  a  constant  opportunity  for  sexual 
intercourse  and  a  great  deal  depends  on  the  nature  of  the  wife 
whether  abstinence  is  practised  more  or  less.  Excess  is  injurious, 
and  it  is  the  duty  of  the  medical  man  to  warn  against  it  those 
who  are  subject  to  heart  disease,  and  to  recommend  moderation. 
The  occupation  of  separate  bedrooms  is  in  such  cases  advisable. 
But  it  is  also  well  to  remember  that  the  sexual  requirement 
varies  in  different  individuals  according  to  their  temperament 
and  that  exaggerated  abstinence  often  does  more  harm  than 
good.  As  the  wife  is  on  an  average  the  more  passive  partner 
at  the  exercise  of  the  sexual  act,  it  will  often  be  advisable,  where 
she  is  the  victim  of  heart  disease,  for  the  medical  man  to  give 
to  the  husband  the  necessary  instructions. 

We  must  now  briefly  refer  to  the  cases  in  which  it  is  impera- 
tive to  recommend  to  women  suffering  from  heart  disease  the 
avoidance  of  pregnancies.  As  absolute  continence  from  all 
sexual  intercourse  is  indicated  in  the  severest  cases  only,  and  as 
on  the  other  hand  there  is  no  safe  protection  against  the  occur- 
rence of  conception  in  any  other  but  absolute  continence,  con- 
ception must  be  prevented  as  far  as  possible.  This  is  not  the 


DISEASES  OF  THE  FASCULAR  SYSTEM     351 

place  to  enter  into  a  detailed  description  of  the  various  methods 
which  are  being  adopted  towards  this  object,  but  it  is  necessary 
to  point  out  that  the  most  prevalent  custom  by  which  conception 
is  avoided,  namely  the  coitus  interruptus,  is  absolutely  to  be 
condemned.  It  has  been  proved  that  this  form  of  intercourse 
is  capable  of  causing  even  in  healthy  women  cardiac  complaints 
and  even  severe  neuroses  of  the  heart.  (Kisch.)  This  is  much 
more  likely  to  happen  in  women  suffering  from  heart  disease. 
The  cause  of  the  injury  lies  in  the  circumstance  that  an  unbear- 
able amount  of  attention,  while  the  excitement  is  at  its  highest 
point  and  the  desire  as  yet  ungratified,  is  bound  to  cause  a  very 
severe  strain  on  the  heart. 

Lactation. — We  come  now  to  the  question  of  lactation. 
Women  with  heart  trouble  must  as  a  rule  be  prohibited  from 
suckling,  but  there  may  be  cases  now  and  then  where  a  woman 
with  a  well-compensated  cardiac  defect  has  undergone  the 
ordeals  of  pregnancy — if  we  may  say  so — physiologically,  and 
where  lactation  with  its  accompanying  regular  habits  necessary 
in  the  interest  of  the  child,  will  probably  be  of  decided  advan- 
tage. Additional  help  can  also  be  expected  from  the  well- 
known  tendency  of  the  genital  organs  to  return  to  their  normal 
condition  more  successfully  in  women  who  suckle  their  children. 
The  physician  will  therefore  have  to  use  his  discretion  in  every 
individual  case.  Fellner  has  shown  that  considerable  fluctua- 
tions in  the  blood  pressure  take  place  during  lactation,  and  we 
must  consequently  be  very  careful  on  the  point.  Now-a-days 
when  so  many  mothers  unfortunately  omit  to  suckle  their  own 
infants  for  no  other  reason  than  their  convenience,  there  is  not 
much  fear  that  the  advice  to  abstain  from  lactation  will  not  be 
strictly  followed. 

II.  Diseases  of  the  arteries. — Arterio-sclerosis. — 
Of  the  diseases  of  the  arteries  those  which  have  any  bearings 
on  our  subject  are  arterio-sclerosis  and  aneurysm. 

Heredity  plays  in  arterio-sclerosis  a  more  important  part 
than  in  the  diseases  of  the  heart  described  above. 

Just  as  very  few  people  would  break  off  a  contemplated 
marriage  with  an  individual  in  whose  family  there  have  been 
frequent  cases  of  arterio-sclerosis,  so  the  physician  has  no  right 


352  HEALTH,  DISEASE,  MARRIAGE 

to  warn  against  the  contraction  of  such  marriages,  as  he  would 
be  justified  in  doing  in  cases  of  tuberculosis  or  insanity.  For 
heredity  is  not  the  only  powerful  factor;  it  only  creates  the 
foundation  for  the  disease  which  may  possibly  be  averted  by 
avoiding  the  well-known  injurious  influences  which  are  demon- 
strably  of  the  greatest  importance  in  the  etiology  of  arterio- 
sclerosis, such  as  f.  i.  alcoholism. 

Every  individual  acquires  in  the  end  a  more  or  less  pro- 
nounced degree  of  arterio-sclerosis  if  he  lives  long  enough,  in 
other  words,  the  atheromatous  degeneration  of  the  blood-vessel 
walls  may  be  regarded  almost  as  a  physiological  accompaniment 
of  advanced  age.  We  look  upon  arterio-sclerosis  as  a  diseased 
condition  only  if  it  occurs  in  comparatively  young  people  and  if 
it  occasions  disturbances  of  health.  It  is  naturally  impossible 
to  lay  down  fixed  numerical  age-limits.  But  as  a  rule  marriages 
are  concluded  at  an  early  age,  that  is,  at  a  time  when  arterio- 
sclerosis is  rare,  between  the  ages  of  20  and  30.  The  injurious 
influence  of  old-age  marriages  is  well-known,  and  we  are  not 
far  wrong  if  we  attribute  this  injurious  influence  to  a  great 
extent  to  the  sexual  intercourse.  Men  of  50  and  upwards  who 
have  often  been  previously  sexually  abstemious  marry  as  a  rule 
women  considerably  younger  than  themselves.  The  sexual  con- 
nexion is  carried  out  regularly  and  generally  too  often  for  a  man 
getting  on  in  years.  The  desire  is  out  of  proportion  not  to  the 
sexual  capacity  of  the  individual  in  question,  but  to  the  amount 
which  is  good  for  him.  Occasionally  such  marriages  are  entered 
into  for  the  sole  desire  to  have  an  heir,  and  this  wish  is  then  the 
cause  of  an  exaggerated  sexual  intercourse. 

This  is  why  we  often  see  elderly  men  who  had  up  to  their 
marriage  been  considered  strong  and  healthy  die  soon  after 
their  entrance  into  such  new  and  unaccustomed  conditions. 

Each  sexual  act  causes  an  alteration  in  the  blood-vascular 
system,  a  not  inconsiderable  increase  in  the  blood  pressure,  and 
namely  more  in  the  man  than  in  the  woman.  This  increased 
blood-pressure  which  is  easily  withstood  by  the  elastic  vessels  of 
young  people  is  too  much  for  the  atheromatous  arteries  of  the 
aged.  To  this  is  also  added  the  unavoidable  over-exertion  of 
the  respiration  and  of  the  heart's  action.  Sudden  death  during 


DISEASES  OF  THE  VASCULAR  SYSTEM     353 

the  performance  of  coitus  is  by  no  means  rare  among  old  men. 
It  is  the  duty  of  the  physician  under  such  circumstances  to  speak 
a  word  of  warning — particularly  so,  considering  that  it  is  chiefly 
in  the  case  of  men  who  think  that  there  is  nothing  the  matter 
with  them,  and  in  whom  the  arterio-sclerosis  gives  rise  to  no 
clinical  symptoms,  that  this  necessity  exists — and  to  recommend 
extreme  sexual  moderation.  Where  the  prohibition  of  marriage 
is  called-for,  a  great  deal  naturally  depends  on  the  extent  of  the 
disease  and  on  its  situation,  just  as  the  general  prognosis  of  the 
malady  also  depends  upon  the  seat  of  the  lesion. 

The  more  vital  the  organ  whose  blood-vessels  have  become 
sclerotic  the  more  dangerous  the  illness.  If  we  differentiate, 
like  Huchard,  arterio-sclerosis  according  to  its  situation,  we 
find  that  patients  who  exhibit  a  cardiac1  or  cerebral  picture  seem 
in  greater  danger  than  those  who  present  the  type  of  renal  man- 
ifestations. The  latter,  again,  seem  in  greater  danger  than  the 
patients  who  show  only  outward  signs  of  arterio-sclerosis,  but 
no  clinical  symptoms  or  only  such  that  proceed  from  less  vital 
organs.  The  most  important  in  any  case  is  the  sclerosis  of  the 
coronary  arteries  or  their  manifestation,  true  angina  pectoris. 
There  are  doubtless  cases  of  true  angina  pectoris  in  which  after 
one  severe  attack  the  symptoms  diminish  gradually  in  conse- 
quence of  the  proper  treatment  and  a  judicious  mode  of  life, 
so  that  they  appear  at  very  long  intervals  or  disappear  even 
altogether.  Under  such  circumstances  marriage  and  its  conse- 
quences are  apparently  well  borne.  But  after  an  interval  extend- 
ing over  some  years  a  relapse  occurs,  or  a  slowly-growing  chronic 
heart-disease  develops,  with  asthmatic  conditions  which  force  the 
angina  pectoris  into  the  background.  We  have  then  a  chronic 
myocarditis  with  dilatation  and  with  the  symptoms  of  cardiac 
asthma. 

We  can  distinguish  in  angina  pectoris  several  forms  of  its 
course :  (  i )  Acute  cases :  Sudden  death,  rapid  closure  or  consid- 
erable stenosis  of  the  coronary  arteries;  (2)  Sub-acute  cases: 
gradual  stenosis  of  the  coronary  arteries,  fibrous  degeneration, 
changes  in  the  heart,  especially  at  the  apex;  (3)  chronic  cases, 
fibrous  myocarditis;  (4)  mild  cases  of  angina  pectoris.  In  the 

^Cf.  Braun,  Therapie  d.  Herzkr. 


354  HEALTH,  DISEASE,  MARRIAGE 

first  3  forms  the  physician  is  entitled  and  even  obliged  to 
prohibit  marriage  unhesitatingly.  But  the  symptoms  are  gen- 
erally so  severe,  the  attacks  so  portentous  of  evil,  and  the 
intervals  between  them  so  distinctly  productive  of  a  feeling  of 
illness  that  the  patients  are  hardly  likely  to  think  of  marriage. 
It  is  different  in  the  mild  cases.  There  we  have  chiefly  difficul- 
ties of  differential  diagnosis  to  contend  against,  for  similar 
symptoms  occur  in  other  cardiac  affections  as  well,  and  there 
undoubtedly  exists  an  angina  pectoris  neurasthenica  vasomo- 
toria.  Where  the  angina  pectoris  is  a  symptom  of  such  another 
disease  of  the  heart,  the  rules  laid  down  above  are  to  be  applied. 
In  mild  cases  of  true  angina  pectoris  the  physician  will  advise 
against  marriage;  married  individuals  will  have  to  be  recom- 
mended moderation,  especially  in  sexual  intercourse.  Where 
the  doctor  thinks  that  there  are  indications  of  sclerosis  in  the 
cerebral  arteries  he  must  adopt  the  same  attitude  as  in  cases 
of  severe  angina  pectoris.  The  arterio-sclerotic  cirrhosis  of  the 
kidney  dictates  the  same  precautionary  conduct  as  that  indicated 
in  granular  atrophy  generally  which  will  be  discussed  in  another 
part. 

Especial  care  is  necessary  in  cases  of  paroxysmal  tachycardia. 
The  main  thing  in  this  complaint  is  probably  a  correct  diagnosis, 
since  a  confusion  with  true  angina  pectoris  is  sometimes  possible, 
and  occasional  attacks  of  quickened  pulse  frequently  occur  in 
various  cardiac  affections.  If  we  understand  by  paroxysmal 
tachycardia  only  those  cases  in  which  there  is  no  organic  disease, 
and  which  are  consequently  purely  neurotic,  there  is  no  reason 
to  oppose  marriage  as  a  matter  of  principle.  Where  the  attacks 
happen  in  people  already  married,  the  doctor  must  investigate 
whether  they  are  not  perhaps  associated  with  sexual  over-indul- 
gence and  give  his  instructions  accordingly.  Pregnancy  need 
not  be  prohibited  in  principle,  but  if  the  attacks  should  during 
utero-gestation  become  alarming  or  unmanageable,  it  might 
become  imperative  to  induce  premature  labour. 

If  we  follow  Rosenbach1  in  distinguishing  two  forms  of 
bradycardia,  namely:  (i)  the  functional  form  which  appears 


^Rosenbach,  Die  Krankheiten  d.  Herzens  u.  ihre  Behandlung. 


DISEASES  OF  THE  OSCULAR  SYSTEM     355 

as  a  consequence  of  the  irritation  of  the  inhibitory  system  of 
the  heart  and  which  is  in  so  far  always  benign  in  its  course 
seeing  that  it  can  take  place  only  where  the  irritability  of  the 
myocardium  is  normal,  and  (2)  the  form  which  is  produced  by 
a  change  in  the  irritability  of  the  heart-muscle  or  of  the  heart- 
centres  themselves  and  which  is  as  a  rule  irreparable,  or  at 
least  prognostically  very  unfavourable, — if  we  admit  the  exist- 
ence of  these  two  forms,  then  the  indications  arising  in  regard  to 
marriage  are  quite  clear.  In  the  first  form  we  must  apply  the 
conclusions  which  we  adopt  in  nervous  paroxysmal  tachycardia, 
the  second  form  is  always  a  sign  of  myocardic  incompetence, 
and  it  necessitates  therefore  the  precautions  which  are  dictated 
by  cardiac  insufficiency  in  general. 

Where  attacks  of  tachycardia  or  bradycardia  appear  there- 
fore as  symptoms  of  organic  heart-disease  or  of  pronounced 
arterio-sclerosis  they  are  signs  of  bad  omen;  if  one  attack  is 
surmounted  it  is  advisable,  if  pregnancy  exists,  to  interrupt 
the  same  before  further  disturbances  of  compensation  arise 
which  would  render  medical  help  tardy  and  nugatory. 

The  more  active  part  in  sexual  intercourse  is  played  by  the 
husband,  and  for  this  reason  he  is  in  greater  danger  than  the 
wife.  On  the  other  hand,  pregnancy  causes  in  the  latter  an 
alteration  in  her  normal  condition  which  is  to  begin  with  the 
limit  of  what  may  be  regarded  as  physiological. 

In  the  etiology  of  arterio-sclerosis  the  increase  in  the  blood- 
pressure  is  given  as  one  of  the  principal  causes,  without  regard 
to  the  circumstances  upon  which  this  blood-pressure  depends;  on 
the  other  hand  it  is  proved  that  women  are  comparatively  far 
more  rarely  attacked  by  arterio-sclerosis  than  men,  and  that 
women  who  have  undergone  pregnancy  extremely  often  do  not 
in  spite  of  the  increase  in  the  blood-pressure  at  every  pregnancy 
suffer  from  the  disease  more  often  than  those  who  have  never 
borne  children.  Nevertheless  this  physiological  increase  in  the 
blood-pressure  during  pregnancy  is  bound  to  have  injurious 
if  not  dangerous  results  where  it  affects  a  woman  whose  blood- 
vessels are  already  diseased.  But  conception  seldom  happens 
in  women  with  well-marked  arterio-sclerosis ;  such  women  have 
generally  reached  the  menopause. 


356  HEALTH,  DISEASE,  MARRIAGE 

An  existing  arterio-sclerosis  may  during  pregnancy  become 
aggravated.  Apart  from  the  increased  demands  which  gesta- 
tion makes  upon  the  circulatory  apparatus,  it  is  the  minor  ail- 
ments which  healthy  women  withstand  easily,  that  play  an 
important  part  in  the  case  of  those  affected  with  arterio-sclerosis. 
It  is  sufficient  to  mention  the  frequent  tendency  to  nausea  and 
vomiting  as  an  example  of  the  best-known  of  these  ail- 
ments. 

If  the  pregnancy  itself  is  tided  over  without  any  material 
aggravation  of  the  complaint,  danger  may  be  caused  by  the 
parturition.  Every  excessive  physical  exertion  is  capable  of 
producing  the  rupture  of  a  sclerotic  artery  in  a  vital  organ  as 
illustrated  by  the  above-mentioned  case  of  Simpson.  Whether 
the  abdominal  pressure  is  applied  during  defalcation  or  whether 
it  undergoes  a  great  strain  during  the  expulsion  stage  of  labour 
is  immaterial  as  far  as  the  result  is  concerned.  The  duty  of 
the  medical  attendant  in  such  cases  is  therefore  to  relieve  the 
parturient  woman  of  the  exertion  of  the  labour,  that  is,  to 
complete  the  latter  artificially  and  under  an  anaesthetic,  which 
is  under  the  circumstances  the  lesser  of  two  evils. 

Aneurysm. — With  regard  to  aneurysm  there  is  on  the 
whole  nothing  more  to  be  said  than  was  said  with  regard  to 
severe  arterio-sclerosis,  namely  that  it  is  the  duty  of  the  physi- 
cian to  warn  against  marriage,  to  recommend  the  utmost  mod- 
eration in  the  exercise  of  sexual  intercourse  and  to  prohibit 
pregnancy  as  far  as  possible. 

III.  Diseases  of  the  veins. — The  acute  affection 
of  the  veins,  that  is  to  say,  phlebitis,  does  not  concern  us  in  our 
present  theme.  As  regards  phlebo-sclerosis  the  same  rules  are 
applicable  as  were  laid  down  with  respect  to  arterio-sclerosis. 

Schrotter  is  right  in  pointing  out  that  phlebo-sclerosis  pre- 
sents no  clinical  symptoms,  for  it  is  merely  one  of  the  manifesta- 
tions of  general  angio-sclerosis  or  because  it  is  observed  in 
connection  with  diseases  of  the  heart.  As  a  rule  sclerosis  of  the 
veins  is  only  recognised  post  mortem  by  a  microscopical  exam- 
ination. The  tumours  of  veins,  their  tuberculous  and  syphi- 
litic affections  need  not  be  discussed  in  this  place,  for  not  the 
seat  of  the  lesion  is  the  main  and  decisive  thing  in  these  diseases, 


DISEASES  OF  THE  FASCULAR  SYSTEM     357 

but  its  etiology,  particularly  as  isolated  disease  of  the  veins 
hardly  ever  occurs  in  these  cases. 

The  most  frequent  and  most  important  disease  of  the  veins 
is  their  dilatation.  Schrotter  restricts  the  name  "varix"  to  the 
sacculated  distentions,  and  calls  the  uniform  dilatations,  the 
so-called  varicose  veins,  phlebectasis.  Among  the  latter  the 
enlargements  of  the  veins  of  the  lower  extremities  occur  most 
frequently.  Owing  to  their  position  while  the  body  is  in  the 
erect  posture  congestion  takes  place  in  them  more  easily  than 
elsewhere.  Pregnancy  plays  a  very  great  part  in  the  etiology 
of  varicose  veins.  Consequently  the  condition  is  noticed  much 
more  frequently  in  women  than  in  men.  Where  a  dilatation 
of  the  veins  exists  already  it  undergoes  aggravation  as  a  result 
of  pregnancy.  But  the  physician  will  hardly  ever  find  himself 
in  the  necessity  of  having  to  prohibit  a  marriage  on  this  account. 
In  the  case  of  the  lighter  forms  of  ectasis  bandages  are  generally 
sufficient,  and  extreme  dilatations  are  as  a  rule  present  in  older 
women.  The  danger  lies  in  the  possible  occurrence  of  fatal 
haemorrhage,  in  inflammation  and  ulceration,  but  above  every- 
thing in  thrombosis  during  the  puerperal  state.  The  com- 
plaints in  these  severe  cases  are  however  so  great  that  surgical 
treatment  i.  e.,  excision  of  the  veins,  appears  desirable  if  not 
necessary,  especially  as  the  results  are  not  unsatisfactory.  In 
any  case,  it  is  the  duty  of  the  medical  attendant  to  watch  most 
carefully  the  puerperium  of  such  women.  The  recommendation 
of  Lennander1  that  the  foot-end  of  the  bed  should  be  by  about 
10  to  50  cm.  higher  is  worth  adopting.  The  period  of  child- 
bed should  extend  over  at  least  14  days;  this  applies  particularly 
to  the  women  of  the  working-classes  who  are  in  the  habit  of 
getting  up  as  a  rule  during  the  first  week  in  order  to  follow 
their  occupations.  The  doctor  will  often  have  to  point  out  the 
long  duration  of  an  eventual  illness  if  he  cannot  otherwise 
persuade  the  patient  to  prolong  her  lying-in  period  as  much 
as  possible. 

Next  in  frequency  is  the  formation  of  varicose  veins  in  the 
haemorrhoidal  plexus.  Here  also  pregnancy  acts  injuriously; 
but  as  a  rule  the  varicosities  abate  at  its  termination  to  the  same 


'Quoted  after  Schrotter. 


358  HEALTH,  DISEASE,  MARRIAGE 

extent  as  they  increased  in  the  course  of  it.  Extreme  cases 
belong  to  the  domain  of  the  surgeon,  of  course  as  long  as  there 
is  no  pregnancy  existing. 

In  man  there  is  finally  to  be  considered  the  varicocele,  or 
the  formation  of  varicose  veins  in  the  plexus  pampiniformis. 
That  it  is  capable  of  producing  impotence  is  denied  by  Moritz. 
At  any  rate,  it  can,  if  at  all  extensive,  interfere  with  the  sexual 
act  and  operation  is  therefore  in  such  cases  to  be  recommended. 

What  has  been  said  here  applies  to  the  cases  of  essential 
varix.  (Mahillon.)  If  the  phlebectasis  is  only  a  symptom  of 
other  organic  diseases,  if  it  is  the  result  of  cardiac  or  pulmonary 
affections,  or  of  those  of  the  liver  or  the  kidneys,  our  stand- 
point must  vary  accordingly. 

IV.  Lymphatic  system.  —  In  conclusion,  a  few 
words  on  the  diseases  of  the  lymphatic  glands  and  lymphatic 
vessels. 

The  acute  infectious  diseases  do  not  come  within  our  present 
survey.  They  must  be  treated  in  accordance  with  the  principles 
generally  adopted.  We  will  however  mention  the  so-called 
phlegmasia  alba  dolens  which  occurs  comparatively  often  during 
child-bed.  The  opinions  of  authors  on  this  affection  vary. 
Freund  sees  the  primary  cause  in  a  congestion  of  lymph  (lym- 
phatic stasis)  which  leads  finally  to  a  pressure-thrombosis  of 
the  crural  veins,  whilst  others,  f.  i.  Fehling  regard  the  venous 
thrombosis  as  the  cause  of  the  disease. 

Just  as  acute  infectious  diseases  spread  preferably  over  the 
lymphatic  system,  so  chronic  infectious  diseases,  f.  i.  tubercu- 
losis and  syphilis  attack  the  lymphatic  vessels  and  glands;  it  is 
not  here  however  the  attacked  organ  which  is  the  main  consider- 
ation, but  the  nature  of  the  disease. 

Detailed  information  on  these  two  diseases,  as  well  as  on 
scrofula,  will  be  found  in  other  portions  of  this  work. 

Of  the  chronic  diseases  of  the  lymphatic  vessels,  we  have  to 
consider  in  connection  with  our  subject  their  dilatation  only. 
More  so  than  in  the  veins,  various  degrees  of  dilatation  occur 
in  the  lymphatic  vessels.  We  meet  slight  and  harmless  cases  of 
lymphectasis  up  to  enormous  lymph-varices,  insignificant  local 
lymphangiomata  up  to  pronounced  elephantiasis  lymph-angiec- 


DISEASES  OF  THE  VASCULAR  SYSTEM     359 

todes.  Considering  the  rarity  of  the  disease  it  is  not  possible 
to  lay  down  general  rules. 

A  transition  to  the  diseases  of  the  blood  is  formed  by  the 
progressive  hyperplasia  of  the  lymphatic  glands,  of  which  we 
distinguish  two  types,  both  of  which  have  a  malignant  pro- 
gressive character  as  a  common  feature.  One  type  is  repre- 
sented by  a  leukaemic  adenia,  i.  e.,  malignant  lymphoma  with 
changes  in  the  blood  such  as  are  characteristic  of  leukaemia,  and 
the  second  type  by  Hodgkin's  disease  or  lymphatic  pseudo-leu- 
kaemia, i.  e.t  a  progressive  hyperplasia  of  the  lymphatic  glands 
of  a  malignant  nature  which  leads  to  a  fatal  issue  through 
cachexia  and  advancing  anaemia,  there  being  no  leukaemic 
changes  in  the  blood  in  the  latter  form.  As  regards  seriousness, 
they  both  occupy  a  place  midway  between  the  malignant  tumours 
and  the  pernicious  diseases  of  the  blood. 

From  our  point  of  view  we  have  to  consider  a  possible 
complication  of  these  diseases  with  pregnancy.  We  have  no 
right  to  take  up  an  absolutely  pessimistic  attitude,  that  is,  to 
allow  the  pregnancy  to  take  its  course  on  account  of  the  probable 
hopelessness  of  the  illness ;  we  know  that  pregnancy  as  such  pre- 
disposes to  progressive  pernicious  diseases  of  the  blood,  and  an 
immediate  interruption  of  the  gestation  appears  therefore  to 
be  indicated  if  the  loss  of  strength  has  not  gone  too  far. 

The  primary  sarcomata  of  the  lymphatic  glands  belong, 
if  it  is  not  too  late,  to  the  sphere  of  the  surgeon. 

The  secondary  tumours  of  the  lymphatic  glands  offer  such 
an  unfavourable  prognosis  that  the  physician  will  probably 
abstain  from  all  interference. 


XI 

Diseases  of  the  Respiratory  Organs  in   Rela- 
tion   to   Marriage 


XI 

DISEASES  OF  THE  RESPIRATORY  ORGANS 
IN  RELATION  TO  MARRIAGE 

By  S.  Kaminer,  M.D.  (Berlin) 

It  has  already  been  pointed  out  in  the  Introduction  to  this 
work  by  Senator  that  it  is  hardly  ever  acute  diseases  but  princi- 
pally if  not  exclusively  chronic  conditions  which  come  into 
question  with  regard  to  the  contraction  of  marriage  and  the 
happiness  of  married  life.  This  limitation  applies  particularly 
to  the  acute  diseases  of  the  respiratory  organs,  with  respect  to 
which  nothing  special  can  be  said  from  the  point  of  view  of 
their  relationship  to  intended  or  accomplished  marriages. 

I.  Pulmonary  and  laryngeal  tuberculosis. — 
Among  the  chronic  diseases  of  the  respiratory  organs  tubercu- 
losis of  the  lungs  and  larynx  occupies  a  very  prominent  position 
in  this  respect  because  it  is  not  only  the  disease  of  the  individual 
as  such  with  which  we  are  concerned.  It  is  also  as  a  CAUSE 
of  disease  "that  tuberculosis  has  great  pathological  importance," 
inasmuch  as  it  is  owing  to  its  infectiousness  a  source  of  danger 
to  the  person  living  in  the  connubial  state  with  the  sufferer,  as 
well  as  to  their  offspring  who  frequently  inherit  it. 

It  is  necessary  to  point  out  at  once  that  pulmonary  phthisis 
and  pulmonary  tuberculosis  are  two  separate  conceptions  though 
they  are  erroneously  often  taken  as  being  identical.  Virchow 
has  always  insisted  that  there  should  be  a  strict  distinction 
between  them,  though  not  in  the  sense  of  Niemeyer  and  his 
school  who  regarded  phthisis  as  a  physical  dyscrasy  and  fore- 
runner of  pulmonary  tuberculosis.  But  the  pathological-ana- 
tomical picture  and  the  clinical  course  of  the  disease  have 
recently  been  forced  too  much  into  the  background  by  the 


364  HEALTH,  DISEASE,  MARRIAGE 

tubercle  bacillus,  the  causative  agent  present  in  the  tissues  in 
every  stage,  not  only  with  regard  to  nomenclature  but  also  for 
purposes  of  prognosis.  To-day  it  is  only  to  that  symbiosis  of 
the  tubercle  bacillus  with  other  pathogenic  bacteria,  which  is 
of  such  decisive  importance  to  the  course  and  issue  of  the 
disease,  that  the  name  of  consumption  or  phthisis  is  given. 

The  distinctiveness  of  the  two  notions  Tuberculosis  and 
Phthisis  is  in  so  far  of  importance  with  regard  to  the  question 
of  the  contraction  of  marriage  that  whereas  consumptives,  being 
incurable  invalids,  ought  never  to  be  allowed  to  marry,  this 
permission  cannot  be  withheld  from  tuberculous  persons  in  every 
instance  as  a  matter  of  course.  For  the  opinion  as  to  the  mar- 
riageableness  of  tuberculous  individuals  must  depend  entirely 
upon  the  prognosis  of  the  disease  in  general.  Those  who 
regard  every  tuberculous  affection  of  the  lungs  as  absolutely 
incurable  will  of  course  be  opposed  to  it,  and  the  extreme 
result  of  this  view  is  to  be  seen  in  the  law  of  the  State  of 
Indiana  which  prohibits  the  marriage  of  all  tuberculous  persons. 
But  those  who  believe  in  the  curability  of  tuberculosis  and  are 
satisfied  that  the  same  causative  agent  may  give  rise  to  one 
and  the  same  disease  but  one  which  is  variable  in  length,  course 
and  issue  will  not  in  every  case  be  able  to  give  the  same  brief 
answer  to  the  question  whether  and  when  tuberculous  individuals 
may  marry. 

The  success  of  modern  therapeutics  has  resulted  in  an  almost 
general  rejection  of  the  view  that  tuberculosis  is  an  incurable 
disease.  This  success  is  not  due  to  any  specific  remedy  such  as 
creosote,  cinnamic  acid  or  tuberculin  for  each  of  which  great 
merit  is  still  claimed,  but  is  mostly  a  consequence  of  the  cir- 
cumstance that  owing  to  the  more  delicate  diagnostic  aids  at  our 
disposal  we  are  in  a  position  to  recognise  the  disease  at  such 
early  stages  that  its  course  can  as  a  rule  be  influenced  most 
beneficially  by  climatic  treatment  or  physical  dietetic  measures. 
Unfortunately  however  this  favourable  result  cannot  in  spite 
of  early  diagnosis  be  looked  for  in  every  case  and  though  we 
know  it  is  possible  for  a  tuberculous  lung  to  heal  up,  it  is  just 
as  difficult  as  it  was  formerly  to  foretell  at  all  the  course  of 
commencing  cases. 


DISEASES  OF  THE  RESPIRATORY  ORGANS     365 

The  investigations  recently  resumed  by  Naegeli1  on  tuber- 
culous changes  in  the  human  cadaver  have  led  to  such  interest- 
ing results  that,  as  Adolph  Schmidt2  expresses  himself,  a  new 
factor  has  been  thrown  into  the  discussion  on  tuberculosis. 
Naegeli  has  proved  by  the  large  post-mortem  material  of  the 
pathological  institute  of  Zurich  that  tuberculosis  is  rare  but 
mostly  fatal  in  the  first  years  of  childhood  and  more  frequent 
but  not  necessarily  fatal  in  somewhat  older  children.  Of  the 
bodies  of  persons  between  14  and  18  years  old  dissected  by  him 
one  half  had  already  been  attacked  by  tuberculosis  and  in  all 
these  cases  the  process  had  been  active  and  progressive  not  a 
single  one  showing  signs  of  healing.  Between  the  i8th  and 
3Oth  year  almost  every  dissected  body  showed  tuberculous 
changes;  of  these  75%  were  active  and  25%  healed  up.  From 
the  3Oth  year  onward  the  probability  that  active  and  fatal 
tuberculosis  will  be  found  diminishes  while  the  certainty  to  find 
tuberculous  lesions  at  all  remains  absolute;  as  age  advances  the 
number  of  active  and  fatal  cases  of  tuberculosis  diminishes  while 
the  number  of  benign  recoveries  increases. 

These  striking  conclusions  of  Naegeli,  though  their  objec- 
tive justification  may  require  examining  into  and  though  they 
may  apply  to  the  proletariat  only,  must  needs  have  some  influ- 
ence upon  the  estimate  of  tuberculosis  as  an  impediment  to 
marriage.  They  show  that  it  is  for  purposes  of  diagnosis  of  the 
utmost  importance  to  establish  in  every  given  case  whether  we 
have  before  us  a  fresh  and  active  process  or  one  that  has  run 
its  course.  As  long  as  the  microscopic  evidence  of  the  presence 
of  tubercle  bacilli  in  the  sputum  was  looked  upon  as  the  only 
decisive  criterion  of  an  existing  pulmonary  tuberculosis  the  dis- 
appearance of  these  bacilli  was  necessarily  overestimated  as  a 
sign  of  recovery  though  v.  Ley  den3  had  already  in  1884  warned 
us  against  such  a  fallacy.  But  to-day  we  know  with  certainty 
that  the  tubercle  bacilli  may  disappear  from  the  sputum  and 
again  make  their  appearance  without  there  being  in  these 
occurrences  any  positive  evidence  to  justify  us  in  arriving  at  a 


1Virchow's  Archiv.  Vol.  160. 

2Deutsche  Med.  Wochenschrift,  1903.  No.  40. 

"Zeitschr.  fur  klin.  Medizin.  Vol.  8. 


366  HEALTH,  DISEASE,  MARRIAGE 

definite  prognosis.  The  presence  of  tubercle  bacilli  in  the 
sputum  is  consequently  no  more  the  only  decisive  sign  in  prog- 
nosis than  it  is  in  diagnosis  though  it  is  in  both  a  very  valuable 
aid.  This  difficulty  in  making  both  a  diagnosis  and  a  prognosis 
has  not  been  entirely  removed  even  by  Koch's  second  important 
discovery  namely  that  of  Tuberculin.  Koch  had  hoped  that  by 
the  use  of  this  preparation  we  should  be  able  to  diagnose  doubt- 
ful cases  of  "phthisis"  in  which  a  definite  opinion  cannot  be 
formed  as  to  the  nature  of  the  disease  by  a  microscopic  examina- 
tion of  the  sputum  for  bacilli  and  elastic  fibres  or  by  the  aid 
of  physical  signs.  Experiments  on  animals  have  in  most  cases 
confirmed  Koch's  opinion,  but  this  does  not  justify  us  in  drawing 
the  same  conclusions  with  regard  to  man.  The  variability  of 
the  organism  in  the  latter  is  so  enormous  that  pathological 
knowledge  obtained  by  experiments  on  animals  must  often  fail 
when  applied  to  human  beings.1  Moreover  the  statistics  of 
Beck2  quoted  chiefly  in  support  of  Koch's  view  are  capable  of 
being  interpreted  in  a  sense  diametrically  opposed  to  it.  Three 
cases  of  leprosy  reacted  to  tuberculin  with  distinct  general  symp- 
toms; of  1 6  cardiac  cases  10  reacted;  of  31  cases  of  muscular 
rheumatism  23  reacted;  of  17  cases  of  acute  nephritis  4  reacted; 
of  1 06  cases  of  gonorrhoea  59  reacted;  of  145  cases  of  syphilis 
59  reacted,  etc.  Beck  concludes  from  these  figures  that  tuberculin 
is  the  keenest  diagnostic  instrument  for  the  recognition  of  tuber- 
culosis. He  says:  "We  are  justified  when  a  person  reacts  to 
tuberculin  in  inferring  the  presence  of  a  tuberculous  focus, 
whether  it  be  one,  if  ever  so  minute,  in  a  bronchial  gland,  or  a 
small  tubercle  in  the  lung  or  any  other  organ  which  cannot  be 
detected  by  a  physical  examination."  But  he  does  not  give  any 
pathological-anatomical  proofs  in  favour  of  this  conclusion 
which  is  so  important  in  its  consequences.  He  takes  for  granted 
what  in  reality  requires  first  to  be  proved,  and  so  this  very 
work  of  Beck  lends  confirmation  to  the  opinion  probably 
expressed  first  by  Rosenbach3  that  non-tuberculous  individuals 


lMartins,  Pathogenese  inner.  Krankh. 

'Deut.  Med.  Woch.  1899,  No.  9. 

'Arzt  contra  Bakteriologe.   Berlin- Vienna.  Urban  &  Schwarzenberg.  1902. 


DISEASES  OF  THE  RESPIRATORY  ORGANS    367 

also  react  to  tuberculin.1  This  sceptical  attitude  is  possibly 
strengthened  by  the  fact,  proved  beyond  doubt,  that  not  even  all 
individuals,  in  whom  tuberculosis  is  known  with  certainty  to 
exist,  react  to  tuberculin.  Another  conclusion  of  Koch's,  that 
it  would  be  possible  by  the  reaction  to  tuberculin  to  demon- 
strate in  apparently  recovered  cases  of  tuberculosis  of  the  lungs 
or  of  the  joints  whether  the  healing  process  is  fully  accomplished 
or  whether  there  are  any  isolated  foci  left  behind  from  which 
the  disease  might  at  any  subsequent  time  spread  again  like  a 
fire  from  cinders  glimmering  among  the  ashes — this  conclusion 
is  so  far  also  not  yet  shown  to  be  correct  though  it  could  easily 
have  been  proved  by  the  joint  researches  of  a  Zurich  clinician 
along  with  the  Zurich  pathologist  Naegeli. 

The  tubercle  bacillus  being  therefore  no  longer,  and  rightly 
so,  the  prime  and  ultimate  argument  in  diagnosis,  and  since  the 
tuberculin  reaction  is  also  unreliable  in  settling  the  question  of 
complete  recovery,  the  physical  examination  of  the  lungs  has 
again  assumed  that  importance  which  seemed  at  one  time  to 
be  denied  to  it.  For  though  the  causative  agent  may  be  the 
same  in  all  cases  we  must  not  lose  sight  of  the  variability  of 
the  pathological  changes  to  which  it  may  give  rise  and  the  differ- 
ent ways  in  which  the  disease  runs  its  course.  These  different 
physically  demonstrable  pathological  changes  though  they  are 
only  stages  along  the  route  which  the  disease  is  travelling  follow 
one  another  in  most  regular  succession.  It  is  consequently  neces- 
sary in  spite  of  the  importance  attached  to  bacteriological  and 
physical  examination  in  diagnosis  as  well  as  in  prognosis  to 
take  into  consideration  the  clinical  picture,  the  subjective  symp- 
toms and  the  state  of  the  constitution.  The  correct  summation 
of  all  these  factors  is  of  the  greatest  consequence  when  consider- 
ing the  question  of  marriage  in  connection  with  tuberculous 
individuals. 

The  not  very  numerous  authors  who  have  dealt  scientifically 


Translator's  note:  Is  not  the  reaction  of  non-tuberculous  (?)  individ- 
uals to  tuberculin,  taken  in  conjunction  with  Naegeli' s  statistics,  rather  a  con- 
firmation of  the  opinion  that  we  are  all  more  or  less  tuberculous?  I  have 
often  heard  Gerhardt  say :  "So  ein  bischen  tuberculos  sind  wir  alle !"  (Just 
a  bit  tuberculous  we  all  are!) 


368  HEALTH,  DISEASE,  MARRIAGE 

with  the  question  of  the  marriageableness  of  tuberculous  persons 
have  naturally  come  to  different  conclusions  corresponding  to 
their  views  of  the  disease.  Hartsen1  has  recommended  mar- 
riage and  pregnancy  as  invaluable  natural  remedies  in  influenc- 
ing phthisical  processes — phthisical  in  the  sense  of  the  oldest 
nomenclature ;  Firchoiv-  on  the  other  hand,  based  upon  his  sad 
experiences,  has  strongly  protested  against  any  such  marriages. 
He  had  frequently  noticed  in  abstemious  tuberculous  persons 
after  their  marriage  a  development  of  acute  processes  among 
other  organs  in  the  prostate  and  he  had  particularly  often  had 
occasion  in  the  post-mortem  room  to  satisfy  himself  of  the 
severe  aggravation  of  the  disease  caused  by  the  puerperal 
state. 

According  to  Firchow  there  is  nothing  more  common  than 
for  young  people  to  fall  a  prey  to  galloping  tuberculosis  during 
the  first  years  of  their  married  life  and  his  advice  to  medical 
practitioners  is  therefore  that  when  consulted  by  such  patients 
they  should  unhesitatingly  and  without  any  sentimentality  explain 
to  them  the  position  and  the  danger  they  are  incurring  by  mar- 
riage and  let  them  decide  for  themselves.  Of  the  same  opinion 
is  van  Ysendyk?  and  Kirchner*  demands  that  everyone  who  has 
the  power  should  prevent  tuberculous  individuals  from  mar- 
rying. Gerhardt5  also  was  in  principle  opposed  to  the  marriage 
of  tuberculous  persons  though  he  was  not  in  favour  of  enforcing 
the  restriction  by  Draconian  laws.  He  did  not  forget  the 
psychological  influence  which  this  prohibition  might  exercise 
upon  them,  but  without  under-estimating  it  he  considered  the 
psychical  disappointment  of  far  less  importance  than  the  dangers 
of  tuberculosis.  The  only  concession  he  would  grant  was  to 
request  a  year's  delay  before  deciding  definitely  and  this  only 
in  such  cases  where  the  circumstances  made  it  impossible  to 
prohibit  the  marriage  altogether. 


lVirchow"s  Archiv.  Vol.  49. 
'Ibid. 

Von  Ysendyk,  Bulletin  de  1'academie  de  medecine  de  Belgique  1898. 
*Kirchncr,  Bericht  iiber  den  internationalen  Kongress  zur   Bekampfung 
der  Tuberkulose.  1899. 

•Gerhardt,  Zeitschrift  fur  Tuberkulose  und  Heilstattenwesen  1891. 


DISEASES  OF  THE  RESPIRATORY  ORGANS    369 

Von  Leyder?  and  Fiirbringer2  are  not  so  pessimistic  with 
regard  to  the  influence  of  marriage  upon  the  course  of  the 
disease  and  not  so  strict  in  giving  their  consent.  Both  have 
seen  good  results  from  marriage  and  frequently  as  it  happened 
in  the  very  cases  which  they  expected  would  take  an  unfavour- 
able turn.  Though  they  acknowledge  the  dangers  of  marriage 
they  lay  great  stress  on  the  variability  of  the  course  of  tubercu- 
losis and  try  to  make  it  clear  to  the  medical  profession  that  it  is 
their  duty  just  as  often  to  forbid  marriage  as  to  permit  it.  For 
marriage  is  from  the  hygienic  point  of  view  the  most  desirable 
union  of  the  sexes,  but  it  and  its  consequences  demand  such 
increased  activity  on  the  part  of  the  organism  of  both  husband 
and  wife  that  it  is  not  always  possible  for  a  person  afflicted  with 
tuberculosis  to  satisfy  these  demands  for  any  length  of  time. 
Influence  of  marriage  on  the  tuberculosis  of 
the  husband. — The  demand  of  some  hygienists  that  a  man 
should  never  indulge  in  sexual  intercourse  before  marriage,  a 
demand  as  to  the  physiological  justification  of  which  opinions 
are  very  much  divided,  will  probably  remain  for  ever  a  pious 
wish.  The  fact  remains  that  the  exercise  of  sexual  connection 
before  marriage  on  the  part  of  the  man  is  not  by  any  means 
a  rare  occurrence  and  society  is  not  prepared  to  condemn  the 
practice.  It  must  therefore  be  admitted  that  it  is  an  exception 
for  a  man  to  remain  chaste  until  his  marriage.  The  sexual  act 
as  such  is  generally  no  novelty  to  the  newly  married  husband 
and  the  physiological  and  pathological  consequences  of  the 
same  to  a  tuberculous  individual  hardly  ever  become  a  subject 
for  consideration.  Nevertheless  it  must  not  be  overlooked 
that  non-connubial  and  connubial  intercourse  have  very  differ- 
ent effects  upon  the  organism.  Non-connubial  intercourse  does 
not  fatigue  so  much  by  its  frequency,  for  it  is  only  in  very  rare 
cases  that  consumptives  cohabit  with  women,  as  by  the  circum- 
stances accompanying  it  such  as  sleepless  nights  spent  in  public 
places  of  amusement,  increased  sexual  excitement  as  a  conse- 


V.  Leyden,  Diskussion  zu  Gerhardt  Zeitschr.  fiir  Tuberkulose  u.  Heilstat- 
tenwesen,  1891. 

*Furbringer,  Diskussion  zu  Gerhardt,  Zeitschr.  fur  Tuberkulose  u.  Heil- 
stattenwesen,  1891. 


370  HEALTH,  DISEASE,  MARRIAGE 

quence  of  different  stimulants  and  over-indulgence  in  alcohol. 
Jacob  and  Pannwitz1  quote  as  concrete  instances  cases  where 
tuberculous  individuals  having  had  sexual  intercourse  with  pros- 
titutes leave  the  house  immediately  afterwards  either  to  return 
to  their  work  or  to  go  home  in  a  cold  winter-night  thus  exposing 
themselves  to  the  inclemency  of  the  weather.  If  we  also  bear 
in  mind  that  tuberculosis  is  very  frequently  accompanied  by  an 
almost  characteristic  morbid  increase  of  the  sexual  desire  we 
shall  not  easily  underrate  the  ill-effects  of  non-connubial  inter- 
course on  the  health  of  tuberculous  individuals.  Daremberg" 
and  Wol$z  think  that  we  are  for  these  reasons  justified  in  advi- 
sing "cured"  tuberculous  patients  to  marry.  And  indeed  they  are 
quite  right.  Because  from  the  standpoint  of  sexual  hygiene 
marriage  is  to  be  regarded  as  a  blessing  to  the  individual:  the 
sexual  life  assumes  an  even  course;  regularity  takes  the  place 
of  promiscuousness;  sleep  is  not  curtailed — conditions  are  cre- 
ated by  married  life  for  the  exercise  of  sexual  intercourse  which 
are  hygienically  of  the  highest  value  to  the  tuberculous  husband. 

The  question  presents  however  from  the  sociological  point 
of  view  may  serious  disadvantages  particularly  as  regards  the 
proletariat.  The  struggle  for  existence  is  by  marriage  ren- 
dered more  severe.  Though  Jacob  and  Pannwitz  maintain  that 
a  careful  working-man's  wife  can  for  half  the  amount  of  money 
required  by  an  unmarried  man  for  his  keep,  provide  nourish- 
ment more  suitable  for  an  invalid  than  he  may  obtain  at  the 
public  places  which  he  frecuents,  it  must  be  admitted  that  this 
calculation  does  not  apply  in  all  cases.  We  must  bear  in  mind 
that  the  income  of  the  working-man  does  not  increase  by  his 
marriage  but  that  on  the  contrary  fresh  and  considerable  burdens 
are  added  to  his  previous  expenses  chiefly  by  the  procreation  of 
families  which  are  notoriously  among  the  working  classes  as 
a  rule  rather  numerous. 

It  is  a  well-known  fact  that  tuberculous  working-men  gen- 
erally bring  into  the  world  a  number  of  children  which  is  out 


lJacob  und  Pannwitz,  Entstehung  u.  Bekampfung  der  Lungentuberkulose. 
Leipzig  1902. 

1Daremberg,  Notes  sur  le  manage  des  tuberculex.    1890. 

'Felix  Wolff,  Behandlung  der  Lungenschwindsucht.    Wiesbaden  1894. 


DISEASES  OF  THE  RESPIRATORY  ORGANS    371 

of  proportion  to  their  income.  Reibmayr1  in  his  remarkable 
book  has  attempted  to  explain  this  phenomenon  by  the  tendency 
of  nature  to  compensate  for  the  shortcomings  of  procreation 
as  regards  quality  by  a  corresponding  increase  in  quantity  so  that 
where  the  progeny  is  likely  to  be  in  danger  through  inheriting 
some  disease  its  number  may  be  relatively  greater.  However 
that  may  be,  we  have  the  fact  to  reckon  with  as  is  also  proved 
clearly  by  the  statistics  of  RifeL2  With  the  increase  in  the  size 
of  the  household  grows  also  the  quantity  of  the  necessaries 
required  and  consequently  the  labour  of  the  bread-winner,  a 
labour  which  his  weakened  organism  cannot  perform  at  all 
or  only  with  great  difficulty.  Want  and  poverty  soon  make 
their  appearance,  and  nutrition,  the  most  important  factor  in 
the  treatment  of  tuberculous  processes,  suffers  both  in  quantity 
and  quality.  Through  the  numerical  increase  of  the  family  the 
housing  conditions  also  undergo  a  change  for  the  worse,  and 
thus  circumstances  are  created  as  a  consequence  of  marriage 
by  the  unfavourable  social  state  of  the  proletariat  which  are 
inimical  to  the  recovery  of  tuberculous  processes. 

It  is  for  these  reasons  that  the  marriage  of  a  tuberculous 
proletarian  implies  from  a  social  point  of  view  the  deterioration 
rather  than  an  improvement  of  his  economic  position. 

The  struggle  for  existence  claims  also  among  the  upper 
classes  a  proportionate  number  of  victims  though  compared  to 
the  proletariat  they  form  the  exception  rather  than  the  rule. 
It  is  considerations  of  a  social  nature  that  play  here  a  more 
important  part.  Marriage  may  for  instance  be  highly  danger- 
ous to  the  tuberculous  husband  whom  a  passionate  and  vivacious 
wife  is  constantly  dragging  to  parties  and  balls,  to  concerts  or 
the  theatre.  What  is  to  her  a  pleasure  is  to  him  a  burden  and 
therefore  an  enervation  of  his  organism,  a  diminution  of  his 
resistibility. 

Where  there  is  no  indigence  or  want  of  proper  housing 
accommodation  in  the  case  of  the  proletarian,  where  the  well- 
to-do  are  able  and  willing  to  renounce  the  pleasures  and  obliga- 


^Reibmayr,  Die  Ehe  Tuberkuloser  u.  ihre  Folgen.    Leipzig  1894. 
*Riffel,  Mitteilungen  iiber  die  Erblichkeit  und  Infektiositat  der  Schwind- 
sucht.  Braunschweig  1892. 


372  HEALTH,  DISEASE,  MARRIAGE 

tions  compatible  perhaps  with  their  social  position  but  not  with 
their  bodily  constitution,  marriage  may  be  regarded  as  of  the 
highest  hygienic  value  to  the  tuberculous  husband  and  as  a  very 
important  remedy  in  its  effects  upon  the  diseased  condition  as 
such;  otherwise  it  is  only  too  frequently  the  cause  of  rapid 
aggravations. 

Influence  of  marriage  on  the  tuberculosis  of 
the  wife. — As  a  consequence  of  the  modern  organisation  of 
society,  the  part  which  woman  takes  in  the  struggle  for  exist- 
ence is  becoming  greater  from  day  to  day.  The  results  of  this 
struggle  are  more  disagreeably  apparent  in  the  case  of  married 
women  since  the  organism  of  the  latter  is  already  sufficiently 
taxed  by  the  physiological  processes  of  pregnancy  and  child- 
birth. Von  Ley  den  particularly  asks  us  to  remember  that  though 
pregnancy  is  a  physiological  condition  it  is  one  closely  bordering 
on  the  pathologic.  For  this  reason  conception  in  the  case  of  an 
ailing  woman  is  always  to  be  regarded  as  a  more  or  less  serious 
complication. 

And  yet  as  late  as  in  the  middle  of  the  last  century  the  views 
on  the  influence  of  pregnancy  upon  the  tuberculous  process  were 
diametrically  opposed  to  those  of  the  present  day.  The  prev- 
alent opinion  was  that  this  influence  is  a  particularly  favourable 
one.  The  history  of  this  opinion  is  like  that  of  many  others  in 
medical  science;  nobody  knew  how  it  originated,  proofs  of  its 
correctness  were  unobtainable  but  as  it  had  been  circulated 
especially  in  France  by  the  bearers  of  such  weighty  names  as 
Bordeau,  Collen,  Banmes,  Portal,  J.  Frank,  etc.  it  became  the 
common  property  of  the  medical  profession  and  exercised  great 
influence  upon  its  decisions.  Marriage — "ce  remede  banal  de 
families" — was  recognised  by  scientific  medicine  as  a  cure  of 
the  tuberculosis  of  young  girls.  It  is  interesting  to  note  that 
Andral*  the  first  physician  who  made  a  different  observation 
described  it  as  a  rare  occurrence  deviating  from  the  general 
rule.  Subsequently  Grisolle,2  Dubreuil3  and  others  have  by 
numerous  observations  endeavoured  to  destroy  the  legend  of 

'Quoted  by  Lcudet. 

*Grisolle,  De  1'influence  que  la  grossese  et  la  phthisic  exercent  1'une  sur 
1'autre.  Arch,  general.  1850.  Tome  22. 

'Dubreuil,  Bulletin  de  1'academie  de  medecine  de  Paris.   Tome  XVII. 


DISEASES  OF  THE  RESPIRATORY  ORGANS    373, 

the  favourable  influence  of  pregnancy  upon  tuberculosis.  Quite 
recently  the  study  of  this  important  question  has  again  been 
undertaken  with  great  earnestness.  Weber,  Gerhardt,  v.  Ley- 
den,  van  Ysendyk,  and  others  have  often  had  occasion  to  record 
sad  experiences.  The  writer1  also  has  in  a  report  of  50  cases  of 
the  third  medical  clinic  (Senator]  and  of  the  Berlin  Royal  Uni- 
versity policlinic  for  diseases  of  the  lungs  (N.  Wolff)  estab- 
lished in  33  cases  an  aggravation  of  the  tuberculosis  through 
pregnancy  and  only  8  cases  in  which  pregnancy  did  not  exercise 
any  influence  upon  the  course  of  the  disease. 

The  important  part  which  pregnancy  plays  in  the  causation 
and  aggravation  of  pulmonary  tuberculosis  is  also  clearly  shown 
by  the  collective  investigation  of  Jacob  and  Pannwitz  made  by 
them  at  German  sanatoria  for  consumptives.  Kuttner*  Loehn- 
berg,3  A.  Fraenkel*  Hamburger,6  Czempin*  Strassmann,1  etc. 
have  published  interesting  observations,  the  two  first-named 
authors  especially  with  regard  to  the  deleterious  influence  of 
pregnancy  on  tuberculosis  of  the  larynx.  All  these  observations 
and  many  others  establish  with  certainty  the  correctness  of  the 
assertion  that  in  a  very  large  number  of  cases  pregnancy  has 
an  unfavourable  influence  upon  the  course  of  tuberculosis  and 
that  it  is  also  very  often  the  cause  of  its  origin  or  of  the  recru- 
descence of  old  deposits.  The  high  percentage  of  aggravations 
(in  the  writer's  statistics  66%)  is  explained  by  the  nature  of 
the  complication;  morning  sickness  and  loss  of  appetite  which 
cause  great  discomfort  to  even  healthy  pregnant  women  must 
naturally  have  a  severer  effect  upon  tuberculous  individuals, 
because  nutrition  which  is  so  important  an  item  to  them  is 
bound  to  suffer  through  these  gastric  troubles,  troubles  that 
are  difficult  to  remove  even  under  ordinary  circumstances. 
Vomiting  generally  accompanies  these  symptoms  and  its  effect 
is  not  only  an  impairment  of  nutrition  but  it  frequently  pro- 

1Kaminer,  Dt.  Med.  Wochenschr.     1901.    Nr.  30. 

*Kuttner,  Arch.  f.  Laryng.  Bd.   12. 

3Lohnberg,  Munch.  Med.  Wochensch.  1903. 

*A.  Frdnkel,  Vehr.  d.  Vereins  f.  innere  Medizin  1901. 

^Hamburger,  Berl    klin.  Wochensch.  1902. 

'Csempin,  Vehr.  d.  Berl.  Med.  Gesellschaft  1902. 

7Strassmann,  Verh.  d.  Vereins  f.  innere  Med.  1902. 


374  HEALTH,  DISEASE,  MARRIAGE 

duces  haemoptysis  on  account  of  the  convulsive  and  suffocative 
movements  with  which  it  is  associated.  Moreover,  by  the 
forcing  upwards  of  the  diaphragm,  by  the  diminution  in  lung 
volume  (retraction),  by  the  deficient  respiratory  capacity  and 
by  the  development  of  the  placenta,  conditions  are  created 
which  have  a  disturbing  effect  upon  the  circulation  in  the  lungs 
and  the  activity  of  the  right  side  of  the  heart.  This  is  the 
more  important  as  even  at  the  present  day  it  is  not  possible 
entirely  to  deny  that  there  are  certain  relations  between  the  cir- 
culation of  the  blood  in  the  lungs  and  tuberculous  processes 
to  which  they  may  be  subject.  In  the  cases  observed  by  the 
writer  it  appeared  that  the  subjective  and  possibly  also  the 
objective  symptoms  were  more  marked  in  the  first  months  of 
pregnancy  than  in  the  last,  which  is  not  probable  in  view  of 
the  normal  course  of  pregnancy  in  a  healthy  woman.  The 
patient  accommodates  herself  so  to  speak  gradually  to  her 
altered  condition;  she  loses  if  she  is  in  the  first  or  even  second 
stage  of  her  illness  many  of  her  most  distressing  symptoms 
and  both  percussion  and  auscultation  of  the  lungs  do  not  reveal 
any  progress  of  the  disease.  The  condition  seems  to  become 
a  latent  one,  the  patients  do  not  appear  to  suffer  very  severely 
— until  labour  occurs. 

Though  the  reseaches  of  Wintrich,  Kuechenmeister  and 
Dohrn1  have  proved  to  satisfaction  that  the  vital  capacity  of 
the  lungs  is  not  diminished  during  pregnancy  and  that  the 
thorax  is  not  made  smaller  by  the  pregnant  uterus  it  has  never- 
theless been  pointed  out  by  v.  Leyden2  when  discussing  the 
complications  of  pregnancy  by  chronic  diseases  of  the  heart 
that  the  extent  of  the  healthy  organism  is  encroached  upon  in 
the  pregnant  woman  by  the  development  of  the  embryo.  "After 
childbirth  the  conditions  become  again  different,  the  resistance 
to  respiration  grows  less,  the  breathing  gets  stronger  and 
the  possibility  is  by  no  means  excluded  that  respiratory  dis- 
turbances and  congestion  of  the  lungs  will  thus  be  caused  which 
may  become  pronounced  only  gradually  that  is  in  the  first  days 
of  the  puerperium." 


lDohrn,  Monatsschrift  f.  Geburtskunde  Bd.  24. 
*v.  Leyden,  Zeitschrift  f.  klinische  Med.  Bd.  23. 


DISEASES  OF  THE  RESPIRATORY  ORGANS    375 

Of  23  tuberculous  women  observed  by  the  writer  14  died 
from  causes  connected  with  childbirth,  7  of  them  in  the  first 
few  days  after  labour.  What  Gusserow1  emphasised  with 
regard  to  pregnant  women  suffering  from  heart  disease  took 
place  here  also:  they  were  suddenly  called  upon  to  perform  a 
laborious  task  to  which  their  organism  weakened  by  tuberculosis 
and  pregnancy  was  no  longer  equal.  A  great  number  of  cases 
communicated  by  van  Ysendyk,  Jacob  and  Pannwitz,  Mara- 
gliano,2  Hamburger  and  others  ran  a  similar  course.  Accord- 
ing to  A.  Fraenkel  the  rapid  progress  of  tuberculosis  after 
childbirth  is  due  generally  to  a  so-called  aspiration-tuberculosis 
as  defined  by  Hanau;  from  more  or  less  extensive  deposits  in 
a  state  of  disintegration  a  quantity  of  secretion  is  during  the 
act  of  labour  suddenly  aspirated  into  the  bronchi,  thus  giving 
rise  to  a  galloping  tuberculosis  spread  in  lobular  deposits  all 
over  the  lungs.  Of  course  not  all  cases  run  the  same  course; 
different  observations  have  also  been  recorded.  The  writer 
has  seen  a  fairly  large  number  of  cases  of  tuberculous  women 
who  have  stood  the  ordeals  of  childbirth  very  well  and  retained 
their  ability  to  work.  Social  conditions  certainly  have  some 
influence  on  childbirth,  but  the  difference  between  its  conse- 
quences in  a  proletarian  woman  and  those  in  one  who  is 
socially  her  superior  is  not  generally  so  marked  as  to  justify 
Hamburger's  inference  that  special  therapeutic  laws  are  neces- 
sary for  the  former  class.  Tuberculous  working-women  also 
can  at  times  withstand  childbirth,  but  it  is  never  possible  to 
foretell  this  happy  issue  with  anything  like  certainty.  Con- 
ception is  always  in  every  tuberculous  woman  a  serious  danger 
to  health  and  life,  and  the  development  or  expulsion  of  the 
foetus  is  very  frequently  in  apparently  recovered  cases  of  tuber- 
culosis the  cause  of  acute  recrudescences  of  a  hitherto  latent 
disease. 

Equally  fatal  opinions  similar  to  those  on  the  influence  of 
pregnancy  and  childbirth  on  tuberculous  patients  were  prev- 
alent at  the  beginning  of  the  last  century  on  the  subject  of 


^Gusserow,  Verb.  d.  Charite-Aerzte  1899. 

2Maragliano,  Bericht  uber  den  intern.  Kongress  z.  Bekampf.  d.  Tuber- 
kulose  .1899. 


376  HEALTH,  DISEASE,  MARRIAGE 

lactation.  Ellin ger  distinctly  recommended  prolonged  lactation 
as  a  prophylactic  against  tuberculosis.  Grisolle  was  again  the 
first  to  demonstrate  that  lactation  by  tuberculous  women  may 
have  just  as  serious  consequences  for  themselves  as  for  their 
sucklings.  Though  most  of  them  secrete  milk  copiously  the  act 
of  suckling  fatigues  them  considerably  and  the  secretion  dimin- 
ishes perceptibly  in  a  few  weeks  or  ceases  altogether.  The 
writer  saw  not  long  since  a  case  where  a  hitherto  perfectly 
healthy  woman  developed  severe  tuberculosis  during  lactation. 
Gerhardt  and  also  Jacob  and  Pannwitz  forbid  such  suckling 
not  only  in  the  interest  of  the  mothers  but  also  in  that  of  their 
children.  Grisolle  has  noticed  that  the  milk  of  tuberculous 
women  frequently  causes  profuse  diarrhoea  from  the  effects  of 
which  the  infants  quickly  die  if  their  food  is  not  immediately 
changed.  Post-mortem  evidence  of  tuberculous  changes  is  in 
such  cases  unobtainable,  and  this  is  in  so  far  important  as  it  has 
been  asserted  by  some  that  tuberculosis  is  easily  transmissible 
from  mother  to  child  through  the  medium  of  the  milk.  This 
theory  has  as  little  foundation  as  the  opinion  that  the  milk  of 
tuberculous  women  is  as  a  rule  injurious  to  the  digestion  of  the 
suckling,  because  researches  have  so  far  failed  to  demonstrate 
a  constant  alteration  in  the  composition  of  the  milk  of  tuber- 
culous women. 

The  secretion  of  milk  is  according  to  Munk  the  most  exact- 
ing performance  of  the  female  organism.  The  demands  made 
on  the  economy  of  the  latter  are  naturally  much  increased  by  lac- 
tation. The  tuberculous  organism  suffers  by  it  more  than  the 
normal.  The  assimilation  of  food  is  diminished,  the  body- 
weight  decreases  and  a  general  condition  is  created  by  the  act 
of  lactation  which  favours  considerably  a  rapid  development  of 
tuberculous  processes. 

In  estimating  the  influence  of  marriage  and  of  its  conse- 
quences upon  tuberculosis  little  importance  has  been  attached 
to  the  stage  of  the  disease  and  to  its  clinical  form  because  the 
injurious  influence  is  generally  though  not  always  the  same. 
In  the  various  stages  of  the  illness  the  consequences  of  that 
influence  are  accordingly  different.  A  tuberculous  woman  in  the 
third  stage  of  the  disease  is  more  liable  to  die  in  childbirth  than 


DISEASES  OF  THE  RESPIRATORY  ORGANS     377 

one  in  the  first  whose  condition  will  probably  only  become  worse, 
or  than  one  apparently  cured  in  whom  latent  foci  may  break 
out  afresh  and  cause  a  recrudescence  of  the  symptoms. 

Tuberculosis  as  a  cause  of  disease  in  mar- 
ried life. — In  considering  tuberculosis  as  a  cause  of  disease  in 
the  married  state  unequally  great  importance  must  be  attached 
to  the  different  forms  and  different  stages  of  the  disease,  because 
though  tuberculosis  is  not  necessarily  always  infectious  certain 
phases  of  it  present  a  greater  or  less  possibility  of  infection. 
This  fact  is  clearly  established  not  only  by  experiment  but  also 
by  clinical  experience. 

The  doctrine  of  the  contagiousness  of  tuberculosis  is  not 
as  Cornet1  says  the  daughter  of  bacteriology  but  its  mother; 
only  because  of  the  conviction  that  tuberculosis  is  contagious 
has  the  agent  of  the  infection  been  sought  for  again  and  again 
until  it  was  found  in  the  tubercle  bacillus.  That  conviction 
however  was  not  by  any  means  universal,  and  if  there  were  in 
every  century  physicians  of  great  fame  from  Galen  down  to 
Lazare  Riviere,  from  Schenck  von  Grafenberg  down  to  Peter 
Frank  and  Weber  whom  experience  had  taught  that  tuberculosis 
is  transferable  from  man  to  man  by  contagion  they  were  both 
in  number  and  in  the  extent  of  their  observation  far  behind  their 
opponents.  It  is  however  of  interest  in  connection  with  this 
historical  retrospect  to  learn  that  all  the  time  during  which 
tuberculosis  was  regarded  as  a  constitutional  anomaly,  by  far 
the  largest  number  of  exceptions  in  which  the  disease  was 
attributed  to  transmission  were  thought  to  be  due  to  heredity 
in  married  life.  So  according  to  the  standpoint  which  the 
observers  took  with  regard  to  these  facts — whether  they  looked 
upon  them  as  scientific  curiosities  or  whether  they  saw  in  them 
an  eternal  source  of  serious  danger  to  the  community — they 
called  attention  more  or  less  emphatically  to  the  importance  of 
marriage  as  a  disseminator  of  tuberculosis.  They  demonstrated 
numerous  cases  of  tuberculous  husbands  who  had  infected  sev- 
eral wives  in  succession,  and  others  in  which  husband  or  wife 
who  suffered  from  a  protracted  and  fairly  latent  tuberculosis 
had  by  contagion  produced  in  his  or  her  partner  a  far  more 


^Cornet,  Die  Tuberkulose.    Vienna  1903. 


378  HEALTH,  DISEASE,  MARRIAGE 

serious  and  rapidly  fatal  form  of  the  disease.  It  is  certain 
that  in  former  centuries  industrial  activity  with  its  accompany- 
ing hygienic  harms  was  not  as  widespread  as  it  is  in  modern 
times  and  that  the  importance  of  married  life  as  a  generator 
of  disease  was  therefore  relatively  higher  than  it  is  at  the 
present  day.  It  must  also  be  remembered  that  in  a  large 
number  of  the  quoted  cases  the  tuberculosis  of  husband  or  wife 
was  probably  not  the  only  cause  of  disease  in  the  other  partner 
and  that  the  same  noxious  circumstances  might  have  produced 
very  frequently  the  same  disease  in  both  of  them  though  perhaps 
not  at  the  same  time  on  account  of  their  unequal  resistibility. 
Nevertheless  it  should  under  all  circumstances  be  taken  into 
consideration  that  since  tuberculosis  is  according  to  established 
theories  a  disease  which  is  infectious  at  times  the  possibility  of 
infection  cannot  be  favoured  by  anything  so  much  as  by  married 
life. 

Very  frequent  attempts  have  been  made  to  establish  from 
statistics  the  seriousness  of  the  risk  of  infection  run  by  either 
husband  or  wife  where  the  other  partner  is  a  tuberculous  sub- 
ject; but  the  results  and  percentages  obtained  have  never  been 
the  same.  The  German  collective  investigation  shows  out  of 
41  cases  in  which  contagiousness  was  proved  23  cases  of  infec- 
tion between  husband  and  wife  and  vice-versa;  the  proportion 
in  the  American  inquiry  is  158  out  of  262,  in  the  French  107 
out  of  213.  But  the  importance  of  these  figures  is  diminished 
by  the  fallacy  already  mentioned  namely  that  they  do  not  prove 
without  a  doubt  that  the  only  cause  of  the  illness  lay  in  the 
fact  that  the  sufferers  were  married  persons.  For  this  reason 
it  is  not  possible  by  these  figures  to  define  the  amount  of  danger 
and  the  significance  of  tuberculosis  as  a  national  disease;  they 
only  tend  to  confirm  the  fact.  Jacob  and  Pannwitz  in  their 
investigation  have  dealt  with  this  objection  and  their  results 
constitute  therefore  more  valuable  material.  In  58  cases  in 
which  the  wife  was  tuberculous  before  the  husband  contracted 
the  disease  only  10  showed  no  other  cause  than  infection;  and 
out  of  69  cases  in  which  the  husband  was  tuberculous  before 
the  wife  became  so  42  gave  the  same  result.  It  does  not  how- 
ever appear  to  me  that  these  figures  justify  the  conclusion 


DISEASES  OF  THE  RESPIRATORY  ORGANS     379 

arrived  at  by  the  authors  that  women  exhibit  a  greater  predis- 
position to  become  infected  from  their  tuberculous  husbands, 
although  a  theoretical  reason  for  this  surely  remarkable  infer- 
ence is  discernible  in  the  physiological  burdens  of  woman  (but 
not  in  the  ways  in  which  the  causative  agent  is  known  to  produce 
infection).  It  must  also  be  admitted  that  women  generally 
stay  more  at  home  and  are  thus  for  a  longer  time  exposed  to 
the  influence  of  the  sputum  which  their  husbands  especially 
among  the  working  classes  are  in  the  habit  of  expectorating 
without  any  regard  to  hygienic  precautions.  This  is  perhaps 
the  cause  of  the  disproportion  in  the  percentage. 

Infection  through  sexual  intercourse. — Opinion 
with  regard  to  the  behaviour  of  the  exciting  agent  of  tuber- 
culosis and  consequently  also  with  regard  to  the  mode  of  con- 
veyance of  the  disease  by  the  contagium  vivum  has  since  the 
discovery  of  the  latter  and  also  as  a  result  of  experiments  on 
animals  been  very  much  divided,  hini1  has  reported  in  an  article 
which  he  did  not  live  to  see  printed  and  which  was  consequently 
published  by  Weigert  that  he  had  been  able  to  demonstrate 
tubercle  bacilli  in  the  testicles  and  prostates  of  men  who  had  died 
from  tuberculosis  while  he  could  not  detect  either  in  the  neigh- 
bourhood of  the  bacilli  or  anywhere  else  the  slightest  traces  of 
pathological  tissue-change.  These  results  could  not  be  appre- 
ciated highly  enough  if  they  had  only  been  confirmed.  But 
the  control-researches  instituted  at  the  instigation  of  Birch- 
Hirschfeld  and  Ziegler  by  Walter2  and  fFestermayer3  have 
shown  that  the  presence  of  tubercle  bacilli  in  healthy  genital 
organs  is  an  extraordinarily  rare  event  if  not  an  impossibility. 
Judging  from  what  we  know  to-day  the  probability  is  that  the 
bacilli  stained  by  Jam  were  some  other  kind  of  acid-fast  bac- 
teria, especially  as  he  did  not  support  his  conclusions  by  experi- 
ments on  animals. 

We  are  therefore  bound  to  recognise  that  the  transmission 
of  tuberculosis  through  the  medium  of  the  seminal  fluid  or  the 
sexual  act  respectively  must  be  excluded  from  the  list  of  possi- 


Yam',  Virch.  Arch.  Vol.  103. 
Walter,  Ziegler  Beitrage.  Vol.  XVI. 
Westermayer,  Diss.  Erlangen  1892. 


380  HEALTH,  DISEASE,  MARRIAGE 

bilities  as  long  as  the  genital  organs  are  healthy.  Such  trans- 
mission, however,  is  quite  within  the  range  of  possibility 
when  these  organs  are  diseased  and  both  experience  and 
experiments  have  proved  this  to  be  true.  The  well-known 
experiments  of  Gaertner  and  Cornet  have  shown  that  it  is  possi- 
ble to  infect  a  female  guinea-pig  by  letting  it  cohabit  with  a  buck 
whose  genital  organs  are  tuberculous,  and  clinical  observations 
for  instance  those  of  Schuchart  have  shown  that  a  similar  mode 
of  infection  occurs  occasionally  in  human  beings.  Posner1  has 
recently  with  the  help  of  Pirchow's  post-mortem  material 
endeavoured  to  find  out  whether  secondary  tuberculosis  of  the 
genital  organs  is  frequent  or  rare.  He  says  himself  that  the 
results  ought  perhaps  to  be  multiplied  because  the  reports  are 
naturally  defective  in  the  particulars  referred  to. 

It  must  also  be  admitted  that  observations  of  tuberculous 
changes  in  the  cadaver  frequently  lead  to  far  different  results 
when  they  are  carried  out  with  one  particular  object  in  view. 
(Naegeli.)  Testicles  and  prostate  are  not  usually  examined  for 
tuberculosis  in  ordinary  post-mortem  dissections  unless  there 
are  special  clinical  indications.  This  fallacy  must  be  taken 
into  consideration  when  mention  is  made  of  the  relatively  small 
number  of  cases  of  secondary  uro-genital  tuberculosis.  On  the 
other  hand  Kirchner  points  out  how  insignificant  the  number  of 
these  cases  is  altogether  when  compared  with  the  enormous 
amount  of  post-mortem  work  performed  in  the  course  of  a  year. 
And  if  other  statistics  for  instance  those  of  Schmorl,  Rosenstein, 
Thorn,  etc.,  show  a  somewhat  greater  frequency  we  must  not 
forget  that  many  of  these  metastases  make  their  appearance 
when  the  patients  are  already  in  extremis. 

On  the  whole  it  is  fairly  certain  that  secondary  tuberculosis 
of  the  male  genital  organs  is  relatively  rare  but  that  whenever 
it  is  present  in  a  husband  there  is  a  possibility  of  the  wife 
becoming  infected.  It  is  consequently,  as  Posner  rightly  says, 
of  importance  to  the  practitioner  when  asked  to  give  his  consent 
to  a  marriage  that  he  should  not  overlook  the  possibility  of  a 
tuberculous  affection  of  the  genital  organs. 

Secondary  tuberculous  changes  in  the  female  genital  organs 


1Posner,  Zeitschr.  fur  Tuberkulose  und  Heilstattenwesen  Bd.  II. 


DISEASES  OF  THE  RESPIRATORY  ORGANS    381 

are  even  rarer  than  in  the  male ;  when  they  are  present  the  same 
or  corresponding  inferences  are  applicable. 

Infection  through  the  medium  of  the  spu- 
tum.— The  possibility  of  infection  through  the  medium  of  the 
sputum  or  of  the  faeces  when  they  contain  tubercle  bacilli  plays 
in  married  life  a  far  more  important  part  than  that  of  infection 
through  sexual  intercourse.  Cornet  has  refuted  the  view  of 
the  ubiquity  of  the  tubercle  bacillus  by  ingenious  experiments 
and  he  as  well  as  Tappeiner,  Stohl,  Galtier,  Schiel,  Fischer  and 
others  have  demonstrated  that  dust  containing  tubercle  bacilli 
in  a  dry  but  nevertheless  viable  state  is  a  constant  source  of 
danger  to  individuals  who  are  predisposed  to  tuberculosis.  It 
is  the  merit  of  Fluegge  and  of  his  pupils  to  have  pointed  out 
the  danger  of  infection  through  droplets.  Though  the  harm- 
lessness  of  the  air  expired  by  tuberculous  patients  has  been 
proved  by  numerous  investigations  the  possibility  of  the  trans- 
mission of  tuberculosis  from  mouth  to  mouth — for  instance 
through  kissing — cannot  be  denied.  A  portion  of  the  tubercle 
bacilli  coughed  up  from  the  lungs  may  lodge  in  the  mouth  so 
that  intimate  contact  with  the  patient  is  never  without  its 
dangers.  Constant  cohabitation  extending  over  many  years  in 
the  same  house,  the  occupation  of  the  same  bedroom,  the  inti- 
mate bodily  contact,  the  use  of  the  same  utensils,  the  gradually 
diminishing  prophylaxis — if  it  ever  was  much  in  evidence — as 
a  consequence  of  being  too  familiar  with  it,  all  these  circum- 
stances make  it  almost  impossible  for  the  healthy  husband  or 
wife  to  avoid  infection. 

If  the  tubercle  bacillus  were  the  only  factor  in  the  causation 
of  tuberculosis  the  reciprocal  infection  of  husband  and  wife 
would  not  be  only  very  frequent  but  universal.  But  though  the 
individuals  concerned  may  be  provided  by  nature  with  a  certain 
immunity  against  tuberculosis,  it  is  well  known  that  this  immu- 
nity can  easily  change  into  a  condition  of  an  opposite  character 
by  intercurrent  diseases  such  as  pneumonia,  influenza,  syphilis, 
by  repeated  pregnancies,  or  by  unfavourable  social  circum- 
stances. While  the  tuberculosis  is  a  latent  one  and  while  there 
is  either  no  expectoration  at  all  or  none  containing  any  bacilli 
there  is  of  course  no  danger  of  infection  through  this  source. 


382  HEALTH,  DISEASE,  MARRIAGE 

It  is  however  worth  remembering  that  in  many  tuberculous 
patients  especially  in  those  suffering  from  the  more  fibrous 
forms  a  discharge  of  tubercle  bacilli  takes  place  periodically 
so  that  in  spite  of  very  careful  examination  of  the  sputum  none 
are  detected  for  a  very  considerable  time  until  an  intercurrent 
affection,  possibly  an  attack  of  influenza,  causes  them  to  make 
their  appearance  or  reappearance.  A  negative  result  in  an 
examination  for  tubercle  bacilli  is  therefore  some  guarantee  for 
the  present  but  not  for  the  future.  In  any  case  as  long  and  as 
often  as  a  tuberculous  husband  or  wife  expectorates  sputum 
containing  tubercle  bacilli  he  or  she  is  a  constant  danger  to  the 
other  partner.  For  the  consideration  of  the  prevalence  of 
tuberculosis  as  a  national  disease,  conjugal  life  with  an  infected 
individual  is  therefore  even  at  the  present  day  one  of  the  chief 
factors. 

The  offspring. — The  incontestable  fact  that  tubercu- 
losis occurs  very  often  successively  in  different  generations  of 
the  same  family  is  accountable  for  the  former  conception  of  the 
disease  as  a  constitutional  anomaly.  Though  as  Virchow  says 
the  doctrine  of  heredity  has  received  at  the  hands  of  medical 
science  most  careful  and  prolonged  study  there  was  no  hesita- 
tion in  regarding  as  purely  hereditary  even  the  interrupted 
appearance  of  tuberculosis.  But  when  the  exciting  cause  of 
the  disease  was  discovered  in  the  tubercle  bacillus  some  of  the 
contagionists  went  to  the  other  extreme  of  declaring  every 
repetition  of  tuberculosis  in  the  offspring  as  due  to  nothing 
but  infection  from  their  parents  with  whom  they  are  living 
under  one  roof. 

According  to  our  present  views  it  cannot  be  denied  that 
infection  does  play  an  important  part  in  the  propagation 
of  tuberculosis  among  the  offspring  of  the  tuberculous. 
The  same  factors  which  contribute  to  the  transmission  of 
the  disease  from  spouse  to  spouse  also  contribute  to  its 
transmission  from  parent  to  child,  though  not  perhaps  to  the 
same  extent.  This  applies  not  only  to  the  large  number  of 
cases  where  the  disease  occurs  already  in  the  next  following  gen- 
eration but  also,  though  of  course  not  so  often,  where  several 
generations  happen  to  live  together,  to  those  cases  where  the 


DISEASES  OF  THE  RESPIRATORY  ORGANS    383 

succession  has  been  interrupted.  It  is  well  known  that  children 
are  subject  to  very  many  diseases  of  a  predisposing  character; 
the  injurious  influences  are  frequently,  though  not  as  a  rule, 
the  same  in  the  parents  as  in  the  children;  it  is  therefore  com- 
prehensible that  the  transmission  of  the  parental  tuberculosis 
to  the  offspring  by  the  infection  of  individuals  predisposed  to 
it  occurs  perhaps  just  as  frequently  as  the  transmission  from 
husband  to  wife  or  vice-versa. 

But  the  theory  of  infection  does  not  answer  in  all  cases 
sufficiently,  especially  in  those  where  the  tuberculosis  makes 
its  appearance  not  during  childhood  and  while  the  parents  are 
ill,  but  later  in  life;  and  also  where  tuberculosis  becomes  mani- 
fest in  the  descendants  of  tuberculous  procreators  who  have  been 
dead  for  years  or  possibly  decades. 

The  attempts  to  explain  these  cases  by  the  hereditary  trans- 
mission of  the  infective  germ  i.  e.,  by  germinal  or  placental 
conveyance  of  the  tubercle  bacillus1  have  received  but  scanty 
support  from  the  experiments  of  Wolff,  Gaertner,  Sanchez- 
Toledo,  etc.  and  from  the  observations  of  numerous  patholo- 
gists.  It  is  true  that  a  few  cases  of  transmission  of  maternal 
tuberculosis  have  been  observed  and  described  in  both  human 
and  animal  foetuses  but  their  number  is  so  small  that  it  is  hardly 
possible  to  attach  to  them  any  general  or  practical  importance. 
We  must  consequently  conclude  that  it  is  not  the  bacillus  which 
passes  into  the  offspring  but  certain  bodily  peculiarities  which 
favour  the  development  of  tuberculosis  in  subsequent  years, 
in  a  word,  what  we  call  "predisposition."  (Koch.) 

See2  has  remarked  with  regard  to  this  "predisposition"  that 
the  word  has  only  been  invented  to  hide  our  ignorance,  and 
Cohnheim  also  has  added  to  it  the  epithet  "mystical"  because 
all  the  attempts  to  give  to  this  idea  of  certain  bodily  peculiar- 
ities a  firm  basis  must  really  be  described  as  failures.  For  all 
that,  the  existence  of  what  we  call  "predisposition"  cannot  be 
doubted  even  if  we  are  not  always  in  a  position  to  explain  its 
nature  or  to  explain  it  every  time  in  a  like  manner.  Some 
believe  that  it  is  the  so-called  phthisical  habit  or  tendency  which 


'Compare  with  Orth's  article,  pp.  39-45. 

2De  la  phthisic  bacillaire  des  poumons.     Paris  1884. 


384  HEALTH,  DISEASE,  MARRIAGE 

is  inherited,  others  see  in  the  congenital  smallness  of  the  heart 
the  reason  why  so  many  descendants  of  the  same  family  become 
tuberculous,  and  quite  recently  stress  has  again  been  laid  upon 
certain  articular  anomalies  in  the  thorax  as  being  of  great  impor- 
tance in  the  genesis  of  pulmonary  tuberculosis.  ( Freund. ) 1  These 
different  opinions  are  to  be  accounted  for  by  the  circumstance 
that  "predisposition"  and  "immunity"  do  not  in  a  mathematical 
sense  represent  fixed  sums  but  variable  quantities  for  which 
we  may  substitute  any  value  we  like,  from  zero  to  the  unlimited. 
The  predisposition  may  be  local  for  one  particular  organ  or 
general  for  the  whole  organism,  it  may  last  during  the  whole 
life  of  an  individual  or  only  during  certain  stages  of  the  same, 
it  may  at  times  be  increased  and  at  others  diminished.  Accord- 
ing to  Gottstein's  definition  we  therefore  understand  by  predis- 
position towards  a  certain  contagion  that  variable  quantity 
which  represents  the  reciprocal  relation  between  the  consti- 
tutional strength  of  man  and  the  exciting  capacity  of  a  certain 
bacterium. 

If  we  acknowledge  the  correctness  of  this  definition  of  pre- 
disposition it  is  comprehensible  that  the  bodily  peculiarities 
necessary  for  the  commencement  of  tuberculosis  may  be  either 
acquired  or  inherited,  but  that  they  are  more  frequently  acquired. 
Opinion  can  only  be  divided  on  the  point  whether  definite  rules 
can  be  laid  down  with  regard  to  the  hereditary  transmission 
of  predisposition. 

The  enormous  number  of  existing  statistics  are  of  no  precise 
value  in  the  elucidation  of  these  questions,  because  while  the 
great  majority  of  them,  as  it  can  only  be  expected,  disclose  with 
certainty  how  many  times  tuberculosis  was  present  among  the 
ascendants  of  tuberculous  patients,  they  do  not  record  how 
many  times  a  repetition  of  the  disease  could  not  be  ascertained 
among  the  descendants  of  such  patients.  Only  the  contributions 
of  Leudet*  and  Riffel  offer  material  from  this  point  of  view. 
Leudet  gives  his  experiences  of  a  practice  extending  over 
45  years;  in  143  families  numbering  1485  persons  he  estab- 
lished heredity  in  about  50%  of  the  cases.  The  statistics  of 


'Verb,  der  Berl.  Med.  Gesellsch.  1901  and  1902. 
'Bull,  de  1'acad.  de  Med.  de  Paris,  1885. 


DISEASES  OF  THE  RESPIRATORY  ORGANS    385 

Riffel,  an  elaborate  essay  on  the  mortality  of  tuberculosis  based 
upon  church  registers  extending  over  4  to  5  generations  of  two 
villages  in  Baden,  are  unfortunately  not  objective  in  the  conclu- 
sions of  their  author.  For  Riff  el  denies  the  importance  of  the 
tubercle  bacillus  in  the  genesis  of  tuberculosis,  since  among  the 
cases  mentioned  by  him  he  alleges  not  to  have  found  a  single 
one  which  could  serve  as  an  undeniable  proof  that  tuberculosis 
is  transmissible  by  infection  from  person  to  person.  And  what 
an  important  drawback  absence  of  objectivity  is  in  statistics  is 
shown  by  the  ease  with  which  Kirchner  was  able  to  draw  from 
Riffel's  own  statistics  quite  different  deductions — and  rightly 
so.  Riff  el's  statistics  also  prove  nothing  more  than  that  tuber- 
culosis is  very  frequent  among  the  descendants  of  the  tuber- 
culous. 

But  though  there  may  not  be  any  doubt  about  this  it  is  surely 
a  mistake  to  look  upon  every  child  of  a  tuberculous  individual 
as  Maragliano  and  Hamburger  do  as  a  "new  tuberculous  unit" 
which  is  undoubtedly  destined  to  fall  a  prey  to  tuberculosis  and 
death.  Does  not  experience  teach  us  daily  that  such  descendants 
may  remain  free  from  tuberculosis  as  long  as  they  live  and  on 
the  other  hand  that  some  members  of  such  families  escape  the 
disease,  while  others  are  overtaken  by  the  same  fate  as  their 
procreators?  It  is  not  possible  to  lay  down  any  definite  rules 
and  it  never  will  be  possible  in  spite  of  all  statistics.  Because, 
though  inherited  predisposition  must  be  regarded  as  a  patho- 
logical condition,  Virchow1  has  already  in  his  classical  essay 
on  "Descent  and  Pathology"  pointed  out  that  not  every  patho- 
logical condition  necessitates  the  presence  of  a  disease  or  is 
connected  with  a  disease.  If  the  pathological  condition  of 
increased  predisposition  is  to  become  the  disease  tuberculosis  it 
is  under  all  circumstances  necessary  that  there  should  supervene 
the  exciting  energy  of  the  tubercle  bacillus.  Considering  that 
the  ubiquity  of  the  bacillus  has  been  disproved  it  should, 
theoretically  speaking,  be  possible  to  avoid  infection. 

We  must  however  remember  that  although  the  bacillus  may 
not  be  everywhere,  its  diffusion  is  so  enormous  that  a  premedi- 
tated attempt  to  avoid  all  objects,  places  and  persons  that  may 


*Virch.  Arch.  Vol.  103. 


386  HEALTH,  DISEASE,  MARRIAGE 

possibly  harbour  it  could  only  be  described  as  sisyphean  labour. 
But  since  predisposition  is  a  variable  quantity,  since  it  may  pos- 
sibly be  influenced  during  life  by  therapeutic  measures,  we  may 
conclude  that  not  every  individual  who  has  inherited  the  pre- 
disposition acquires  the  disease  as  a  matter  of  course,  only 
because  the  exciting  energy  of  the  bacillus  is  not  always  great 
enough  and  the  resistibility  of  the  body  not  small  enough  to 
facilitate  the  beginning  of  the  disease.  It  does  not  therefore 
follow  that  a  descendant  is  bound  to  become  tuberculous  even 
if  both  his  parents  were  afflicted  with  tuberculosis.  It  is  only 
thus  that  we  can  explain  how  it  is  that  in  some  families  parental 
tuberculosis  is  not  transmitted  to  the  children  whilst  in  others 
all  the  descendants  with  or  without  exceptions  fall  a  prey  to 
it.  The  question  whether  and  how  often  a  member  of  such  a 
family  who  marries  a  healthy  descendant  of  another  family  not 
so  predisposed  will  bring  into  the  world  children  predisposed 
to  tuberculosis  is  also  unanswerable  and  will  probably  remain 
so  in  spite  of  statistics  because  a  child  is  just  as  apt  to  inherit 
the  constitution  of  its  sound  parent  as  that  of  its  diseased 
one. 

In  almost  all  the  numerous  statistics  which  deal  with  the 
hereditary  transmission  of  tuberculosis  very  seldom  mention 
is  made,  under  the  entry  how  often  the  disease  occurred  among 
the  ascendants  of  tuberculous  individuals,  of  the  mode  and 
time  of  its  origin.  And  yet  this  information  is  of  inestimable 
value  to  the  question  of  heredity.  We  must  take  it  that  it  is 
highly  improbable  that  a  healthy  individual  descending  from 
a  healthy  family  who  becomes  tuberculous  some  time  after 
the  birth  of  his  or  her  children  will  transmit  to  them  an 
increased  predisposition  to  tuberculosis;  it  would  for  instance 
be  hardly  correct  to  consider  so  predisposed  the  descendants  of 
a  diabetic  patient  in  whom  tuberculosis  supervenes  sooner  or 
later  as  a  complication  of  his  or  her  disease.  Or  is  it  right  to 
assume  that  a  descendant  is  predisposed  to  tuberculosis  because 
an  attack  of  pneumonia  in  his  father  ended  not  with  resolution 
but  the  supervention  of  tuberculosis  many  years  after  the  birth 
of  the  former?  These  and  similar  cases  have  nothing  to  do 
with  the  question  of  heredity.  Were  we  to  have  statistics  on 


DISEASES  OF  THE  RESPIRATORY  ORGANS     387 

such  points  also  the  results  would  perhaps  be  different  than 
hitherto. 

Only  if  the  father  or  the  mother  was  predisposed  to  tuber- 
culosis at  the  moment  of  conception  is  there  a  possibility  or 
probability  of  this  predisposition  being  inherited;  with  regard 
to  the  hereditary  transmission  of  the  maternal  predisposition 
we  cannot  even  take  into  consideration  the  period  of  pregnancy 
up  to  the  time  of  labour.1 

Permission  to  marry. —  It  will  therefore  never  be 
possible  to  tell  with  certainty  whether  the  disease  which  was 
present  in  the  parents  will  also  make  its  appearance  in  the 
children.  For  this  reason  it  is  also  impossible  to  lay  down 
any  fixed  laws  with  regard  to  consenting  to  the  marriage  of 
such  individuals  as  are  predisposed  to  tuberculosis.  Material 
or  social  considerations,  occasionally  perhaps  dynastic  motives, 
must  in  each  single  case  influence  the  decision  to  be  arrived  at, 
one  way  or  the  other.  But  if  the  "higher  standpoint  of  causal- 
ity" is  looked  upon  as  justified  in  the  interests  of  the  welfare 
of  succeeding  generations,  if  the  right  is  conceded  to  the  medical 
profession  to  weigh  the  possible  damage  to  the  offspring  in 
opposition  to  the  advantages  of  the  individuals  already  exist- 
ing, it  behoves  us  to  do  our  utmost  to  prevent  the  marriage 
of  individuals  predisposed  to  tuberculosis,  or  at  least  their 
propagation. 

The  attempt  to  restrict  the  marriage  and  propagation  of 
tuberculous  individuals  has  however  been  described  by  Reibmayr 
as  an  unjustifiable  interference  with  the  natural  method  of 
selection.  This  author  tries  to  prove  by  minute  reasoning  and 
especially  on  the  basis  of  the  works  of  Riff  el  and  Ammon  that 
by  the  marriage  of  individuals  affected  with  or  predisposed  to 
tuberculosis  not  an  increased  predisposition  towards  this  disease 
is  inherited,  but  an  increased  resistibility  against  it.  In-breeding 
continuously  practised  by  such  individuals  would  therefore  in 
the  course  of  centuries  result  in  a  complete  immunity  of  the 
human  race  against  tuberculosis.  These  conclusions  though 
ingeniously  arrived  at  have  been  rightly  called  heretical.  They 
are  paradoxical  and  incorrect  analogies  from  natural  philosophy 


aSee  Orth's  article,  pp.  39-45. 


388  HEALTH,  DISEASE,  MARRIAGE 

which  it  would  be  highly  dangerous  to  introduce  into  practice. 
For  according  to  Reibmayrs  erroneous  teaching  we  should 
have  to  regard  the  phthisical  habit  and  the  paralytic  thorax, 
as  Scheimpftug  correctly  points  out,  not  as  symptoms  of  deficient 
development  but  as  signs  of  a  higher  resistibility.  In  spite 
of  the  able  manner  in  which  Reibmayr  endeavours  to  prove 
the  correctness  of  his  proposition  and  the  justification  of  his 
demand  that  the  marriage  and  propagation  of  tuberculous 
individuals  shall  be  encouraged,  experience  seems  to  go  against 
him;  his  theory  is  fortunately  not  practically  realisable. 

The  attempts  of  the  medical  profession  to  prevent  as  far  as  it 
lies  in  its  power  and  without  a  dereliction  of  duty,  the  marriage 
of  individuals  predisposed  to  tuberculosis  will  often  result  in 
failure  on  account  of  the  incompatibility  of  the  advice  with 
material,  physical  or  psychological  circumstances.  For  where  a 
proletarian  f.  i.  consults  his  doctor  before  his  marriage — a  thing 
which  does  not  happen  very  often — he  is  not  likely  to  listen 
seriously  to  a  dissertation  on  the  probabilities  of  the  future. 
Nor  will  persons  belonging  to  the  better  classes  often  be  able 
or  willing  to  sacrifice  their  personal  happiness  or  prospects 
for  the  sake  of  those  coming  after  them.  To  give  up  the  idea 
of  marriage  under  such  circumstances  is  often  an  act  of  heroism 
of  which  we  read  in  novels  but  not  one  of  which  the  average 
man  or  woman  is  capable.  Nevertheless  this  does  not  debar 
the  doctor  from  giving  to  those  who  consult  him  his  unbiased 
and  warning  advice. 

In  permitting  tuberculous  individuals  to  marry  it  is  neces- 
sary to  follow  certain  fixed  principles  with  regard  to  the  different 
classes  of  the  disease  and  also  with  regard  to  individual  cases. 
If  we  take  the  advantages  of  marriage  of  tuberculous  people 
on  the  whole  and  compare  them  with  the  disadvantages  and 
dangers,  the  latter  no  doubt  preponderate  over  the  former. 
If  it  is  therefore  necessary  as  a  rule  to  oppose  the  marriage  of 
tuberculously  affected  individuals  with  far  more  energy  than 
that  of  persons  only  hereditarily  predisposed  to  tuberculosis, 
it  is  nevertheless,  in  view  of  what  has  been  said  above,  an 
established  fact  that  circumstances  may  occasionally  arise  where 
the  advantages  of  marriage  outweigh  the  disadvantages,  where 


DISEASES  OF  THE  RESPIRATORY  ORGANS     389 

there  is  either  no  danger  at  all  involved  by  marriage,  or  where, 
if  present,  such  danger  may  be  materially  diminished  by  suitable 
prophylactic  or  therapeutic  measures. 

I  have  in  my  mind  the  following  concrete  case :  A  consider- 
able legacy  was  left  by  will  to  an  inpecunious  individual  with 
double  apical  pulmonary  tuberculosis  by  a  rich  relative  on  condi- 
tion that  he  should  get  married.  The  patient,  a  cautious  and  con- 
siderate man,  who  was  well  aware  of  his  condition,  would 
not  marry  without  the  consent  of  a  medical  man,  and  the 
young  lady  who  was  to  be  his  wife  was  willing  to  undertake 
the  risk  which  was  explained  to  her.  Under  the  circumstances 
I  gave  my  consent  to  the  marriage  without  any  hesitation, 
reflecting  that  an  improved  pecuniary  position  was  more  likely 
to  lead  to  a  permanent  cure. 

Apart  from  such  special  considerations,  it  is  of  the  greatest 
importance  with  reference  to  the  question  whether  tuberculous 
individuals  should  be  allowed  to  marry,  that  differentiation 
should  be  made  between  fresh  and  rapidly  progressing  cases 
and  those  which  are  insidious  or  entirely  at  a  standstill.  This 
is  not  the  place  to  enter  into  a  minute  and  elaborate  discussion 
of  the  delicate  signs  of  complete  recovery  from  tuberculous 
affections;  and  although  it  is  generally  difficult  to  prove,  there 
are  doubtless  many  persons  who  have  years  or  decades  previ- 
ously manifested  signs  of  tuberculous  disease  of  the  lungs,  such 
as  haemoptysis,  but  whose  sputum  does  not  contain  any  bacilli 
and  in  whom  there  are  neither  physical  signs  demonstrating 
the  existence  of  recent  changes  in  the  lung-tissue  nor  subjective 
symptoms,  and  whose  general  state  and  resistibility  may  be 
described  as  perfectly  normal. 

The  result  of  test-injections  of  tuberculin  is  unfortunately 


Translator's  note :  It  would  be  interesting  to  have  the  after-history  of 
this  case.  A  somewhat  similar  one  occurred  in  my  practice  some  years  ago, 
which  had  unfortunately  a  very  sad  ending.  I  was  practically  compelled  to 
consent  to  the  marriage  of  a  young  couple  who  had  committed  a  severe 
indiscretion.  The  circumstances  were  in  every  sense  favourable  except  that 
the  young  man  had  a  family  history  of  consumption,  and  he  himself  showed 
some  early  symptoms.  I  had  reason  to  hope  for  the  best,  but  in  less  than 
2  or  3  years'  time  I  heard  that  the  young  husband  had  died  abroad  from 
galloping  consumption. 


390  HEALTH,  DISEASE,  MARRIAGE 

of  very  little  assistance  in  such  cases,  but  as  far  as  we  can  clini- 
cally prognosticate  at  all  we  are  justified  in  assuming  complete 
recovery,  and  that  such  complete  recovery  does  take  place  very 
frequently  has  been  clearly  shown  by  the  researches  of  Naegeli. 
Under  such  circumstances  and  especially  in  the  case  of  men,  it 
is  advisable  to  explicitly  recommend  marriage,  provided,  of 
course,  that  there  are  no  unfavourable  economic  conditions 
to  centra-indicate  it.  Where  ordinary  human  foresight  tells 
us  that  in  all  probability  the  material  circumstances  will  by  mar- 
riage undergo  a  change  for  the  worse,  that  want  and  conse- 
quently insufficient  nutrition  and  an  increased  amount  of  manual 
labour  will  in  all  likelihood  cause  the  recrudescence  of  old 
deposits,  our  advice  will  certainly  tend  in  a  different  direction. 
In  the  case  of  females  it  is  necessary  to  be  still  more  careful  in 
giving  the  consent  to  marriage,  for  the  dangers  of  pregnancy 
and  labour  as  causes  of  severe  relapses  must  not  in  any  way 
be  underrated. 

In  fresh  cases  of  pulmonary  tuberculosis  the  sex  of  the  indi- 
vidual is  not  of  very  great  importance  with  regard  to  the 
decision  whether  marriage  should  be  permitted,  seeing  that  this 
permission  will  probably  have  to  be  withheld  in  every  case.  Ex- 
ceptions, like  the  one  mentioned  above,  only  confirm  the  rule  of 
prohibition.  For  it  is  impossible  without  constant  observation  to 
prognosticate  the  further  course  of  the  disease  with  anything 
like  certainty.  And  as  the  probability  is  great  that  the  duration 
of  life  will  be  shortened  where  tuberculosis  has  made  its  appear- 
ance the  prohibition  of  marriage  is  a  necessary  medical  pre- 
caution. The  expectoration  of  tubercle  bacilli  in  particular 
requires  most  careful  consideration;  a  married  individual  who 
expectorates  tubercle  bacilli  is  a  highly  dangerous  source  of 
infection  to  his  or  her  married  partner,  and  for  this  reason 
alone  such  persons  must  be  dissuaded  from  marrying  after 
being  enlightened  on  the  subject.  On  the  other  hand,  it  would 
be  disastrous  always  to  draw  a  contrary  conclusion  from  a  nega- 
tive result  of  an  examination  of  the  sputum,  and  to  be  thereby 
influenced  in  a  sense  favourable  to  marriage;  in  this  important 
question  also,  the  condition  of  the  sputum  must  not  be  the  only 
determining  factor.  The  presence  of  secondary  tuberculosis 


DISEASES  OF  THE  RESPIRATORY  ORGANS    391 

of  the  genitourinary  organs  is  for  the  same  reasons  a  strict 
contra-indication  against  marriage. 

Gerhardt  has  recommended  that  tuberculous  persons  should 
be  advised  to  wait  at  least  one  year  before  being  permitted  to 
marry.  This  interval  appears  to  Jacob  and  Pannwitz  to  be 
too  short.  From  what  we  know  of  the  biology  of  the  tubercle 
bacillus,  its  vitality  and  activity  in  the  human  body  during  a 
period  of  3  years  is  by  no  means  impossible,  and  3  years  should 
therefore  be  the  minimum  interval  of  postponement.  If  there 
are  no  signs  of  the  progress  of  the  disease  during  that  time, 
such  as  haemoptysis,  pleurisy,  physical  signs  of  fresh  specific 
catarrh  over  the  apices  of  the  lungs,  renewed  expectoration  of 
tubercle  bacilli,  strong  subjective  symptoms,  emaciation  and 
night-sweats,  the  possibility  of  consent  to  the  marriage  may 
come  into  consideration.  It  is  moreover  always  the  duty  of  the 
medical  man,  as  Firchow  would  have  it,  to  ignore  all  physical 
and  sentimental  motives  and  to  call  the  attention  of  the  patients 
to  the  uncertainty  of  the  latent  stage  of  tuberculosis.  In  any 
case  the  doctor  must  see  that  the  candidate  for  marriage  does 
not  leave  his  intended  wife  or  her  relatives  in  the  dark  with 
respect  to  his  condition  and  the  uncertainty  of  the  prognosis, 
where  he  cannot  for  reasons  of  professional  secrecy  convey 
the  information  himself.  Because  the  dangers  of  moral  dis- 
appointment are  never  so  great  as  those  of  even  latent  tuber- 
culosis. 

It  is  therefore  clear  that  the  decision  on  the  part  of  the 
medical  man  as  to  whether  a  tuberculous  individual  may  marry 
or  not,  is  one  of  the  most  responsible  which  fall  within  his 
province.  But  just  as  important  and  just  as  significant  are  his 
duties  and  obligations  towards  the  family,  where  one  or  the 
other  of  the  married  partners  is  the  subject  of  tuberculosis. 

Sexual  intercourse  during  married  life. — In 
such  cases  it  will  hardly  be  possible  to  avoid  instructing  both 
husband  and  wife  with  regard  to  the  frequency  of  their  sexual 
intercourse,  a  point  which  is  still  in  the  eyes  of  many  forbidden 
ground.  Seeing  that  tuberculous  individuals  are  often  the 
subjects  of  increased  sexual  desire,  the  danger  and  injuriousness 
of  too  frequent  sexual  intercourse  must  be  pointed  out  to  them, 


392  HEALTH,  DISEASE,  MARRIAGE 

and  attention  must  be  paid  as  far  as  possible  to  all  those  ele- 
ments which  co-operate  in  producing  the  increased  desire,  and 
the  necessary  therapeutic  treatment  must  be  instituted  towards 
its  removal.  Where  the  genital  organs  exhibit  tuberculous 
changes  intercourse  will  on  account  of  the  danger  of  infection 
to  the  other  partner  have  to  be  permitted  in  the  form  of  con- 
domatic  coitus  only. 

Prophylaxis  in  the  married  life  of  tubercu- 
lous persons. —  From  a  prophylactic  point  of  view  it  is 
desirable  where  the  pecuniary  circumstances  permit  it  that  the 
tuberculous  husband  or  wife,  especially  if  the  expectoration 
contains  tubercle  bacilli  should  occupy  a  separate  bedroom. 
Where  this  is  not  possible  it  is  at  least  advisable  that  the  beds 
of  Husband  and  wife  should  be  placed  as  far  from  one  another 
as  the  size  of  the  room  will  allow.  The  remaining  prophylactic 
precautions  are  the  same  as  those  indicated  in  every  case  of 
tuberculosis.  Kissing  must  be  altogether  prohibited,  and  not 
only  on  the  mouth.  A  careful  removal  of  the  sputum  and  dis- 
infection of  the  sputum-holder  is  essential  as  are  also  the  use 
of  separate  utensils,  the  adoption  of  certain  precautions  with 
respect  to  personal  linen,  special  cleanliness  of  water-closets 
where  one  of  the  inmates  of  the  house  suffers  from  secondary 
intestinal  tuberculosis,  etc.,  etc. 

Artificial  abortion. — In  addition  to  these  general  pro- 
phylactic measures  special  importance  attaches  to  those  indicated 
when  a  tuberculous  woman  becomes  pregnant  or  when  a  woman 
exhibits  undoubted  signs  of  pulmonary  tuberculosis  in  the  course 
of  her  pregnancy.  For  years,  even  after  pregnancy  had  ceased 
to  be  regarded  as  a  natural  aid  in  the  treatment  of  tuberculous 
processes,  the  medical  profession  considered  it  the  right  thing 
in  such  cases  to  remain  as  a  rule  silent  spectators.  Partly  from 
religious  scruples,  partly  from  legal  considerations1  and  partly 
also  because  the  significance  and  dangerousness  of  the  inter- 
ference were  not  thought  commensurate  with  its  probable  advan- 
tages, medical  men  were  averse  to  the  idea  of  arresting  the 
pregnancy  prematurely,  by  the  induction  of  artificial  abortion 
or  of  premature  labour. 


lKossmann.  Verb.  d.  Berl.  Med.  Gesells.  1901. 


DISEASES  OF  THE  RESPIRATORY  ORGANS     393 

The  first  to  anticipate  beneficial  results  from  such  a  course  of 
action  was  v.  Leyden  who  says  in  the  conclusion  of  his  work 
on  the  complication  of  pregnancy  by  chronic  diseases  of  the 
heart  as  follows:  "The  question,  whether  in  cases  of  tuber- 
culosis it  is  not  possible  to  arrest  occasionally  the  weakness 
of  the  heart  and  to  preserve  the  life  of  the  woman  by  putting 
a  premature  end  to  the  pregnancy,  is  of  especial  importance 
on  account  of  its  frequency.  My  experience  tells  me  that 
tuberculosis  in  women  is  doubtless  aggravated  by  repeated 
pregnancies." 

Gerhardt  also,  in  his  lecture  on  the  contraction  of  marriage 
by  tuberculous  individuals,  emphasizes  that  where  a  pregnant 
woman  surely  and  steadily  loses  strength  in  consequence  of 
the  disease  of  the  lungs  the  question,  whether  the  condition  of 
the  mother  justifies  the  medical  man  in  inducing  artificial  abor- 
tion, must  doubtless  be  answered  in  the  affirmative.  Particu- 
larly so,  as  in  cases  where  tuberculosis  makes  its  first  appearance 
at  the  beginning  of  the  pregnancy  a  possibility  to  treat  it  suc- 
cessfully by  the  administration  of  hygienic-dietetic  remedies  can 
often  be  obtained  only  by  the  artificial  interruption  of  the 
pregnancy. 

The  question  of  the  advisability  of  abortion  in  tuberculosis 
has  however  found  an  almost  enthusiastic  supporter  in  Mara- 
gliano:  he  demands  that  the  pregnancy  of  every  tuberculous 
woman  shall  be  artificially  interrupted.  We  must  not  wait 
until  special  disturbances  or  dangers  have  arisen  to  the  patient 
by  the  pregnancy,  either  from  purely  mechanical  conditions 
or  as  a  result  of  disordered  nutrition:  the  more  circumscribed 
the  tuberculosis  and  the  better  the  general  condition  the  more 
this  interference  is  called  for.  The  standpoint  from  which  we 
should  look  at  the  matter  is  not  that  of  symptomatic  advisability, 
but  rather  "the  highest  standpoint  of  causality."  Maragliano 
concludes  literally  as  follows : 

"If  we  mean  seriously  and  intentionally  to  protect  humanity 
against  tuberculosis  it  is  necessary  to  divest  ourselves  entirely 
of  all  sentimentality  with  respect  to  the  hypothetic  rights  of  the 
foetus,  and  to  consider  the  latter  altogether  of  secondary  impor- 
tance as  compared  to  the  mother.  If  we  bear  in  mind  at  the  same 


394  HEALTH.  DISEASE,  MARRIAGE 

time  the  great  influence  which  the  mother  exercises  upon  the 
organism  of  the  future  being,  including  a  possible  transmission 
of  the  disease  to  the  latter,  the  interference  becomes  still  more 
justified,  since  by  it  we  not  only  cause  positive  advantage  to  the 
mother  who  is  saved  from  the  dangers  of  the  pregnancy,  but  we 
at  the  same  time  prevent  the  addition  of  a  further  tuberculous 
unit  to  mankind  in  general." 

Since  1893  Maragliano  has  in  his  clinic  carried  out  this 
principle,  and  his  personal  experience  has  convinced  him  that 
the  patients  get  better  and  are  "cured"  soon  after  the  evacuation 
of  the  uterus. 

With  regard  to  the  interruption  of  the  pregnancy  in  tuber- 
culous women  it  is  necessary  to  distinguish  on  principle  between 
induction  of  abortion  and  induction  of  premature  labour.  Klein- 
ivdchter  and  Schauta  recognise  generally  very  few  indications 
for  the  induction  of  abortion;  the  former,  especially  because 
he  does  not  consider  the  prognosis  absolutely  favourable,  even 
if  the  operation  is  conducted  with  all  possible  care,  seeing  that 
it  produces  a  violent  commotion  in  the  whole  organism  of  the 
woman,  a  circumstance  bound  to  have  great  effect  in  the  case 
of  one  suffering  from  disease;  the  latter  because  he  thinks  the 
result  of  the  operation  very  unreliable. 

In  the  Berlin  Royal  Policlinic  for  patients  with  lung-diseases 
the  question  of  the  advantages  and  disadvantages  of  artificial 
abortion  in  tuberculous  women  has  for  about  4  years  received 
very  careful  consideration.  The  operations  have  been  per- 
formed by  medical  men  with  a  specialist  training,  and  there 
has  never  been  any  complication  or  unfortunate  accident  in  con- 
nection with  the  cases,  a  fact  worth  special  mention  in  view  of 
Kleinwachter's  pessimistic  opinion.  As  regards  the  influence 
of  the  operation  on  the  disease,  the  statistics  published  by  me 
in  1901  show  that  there  has  been  an  aggravation  of  the  condi- 
tion in  30%  of  the  cases,  12%  ended  in  death  after  a  more 
or  less  continued  treatment,  and  70%  remained  at  a  standstill. 
The  cases  which  have  been  admitted  since,  do  not  give  any 
materially  different  percentages.  But  as  to  a  "cure"  such  as 
Maragliano  says  he  has  often  seen,  there  has  not  been,  as  it  was 
fully  to  be  expected,  a  single  one;  for  pregnancy  is  not  the 


DISEASE  OF  THE  RESPIRATORY  ORGANS    395 

exciting  cause  of  pulmonary  phthisis.  Subsequently  Kuttner 
has  included  in  his  observations  the  question  of  the  induction 
of  abortion  in  tuberculosis  of  the  larynx,  and  has  energeti- 
cally recommended  the  operation  in  certain  cases. 

Hamburger  has  in  like  manner  taken  up  a  definite  position 
on  the  question  especially  in  reference  to  working-women,  and 
inclines  to  the  view  of  Maragliano,  the  so-called  "higher  princi- 
ples of  causality."  He  is  in  favour  of  abortion  being  performed 
in  every  tuberculous  working-woman,  if  there  is  no  doubt  about 
the  diagnosis,  and  as  a  decisive  criterion  for  the  latter  he  regards 
the  presence  of  tubercle  bacilli  in  the  sputum.  This  general- 
isation, even  for  special  classes,  is  for  this  reason  not  desirable 
and  occasionally  even  injurious,  because  as  we  have  already 
seen  not  every  case  of  tuberculosis,  not  even  in  working-women, 
is  aggravated  by  pregnancy,  and  because  on  the  other  hand,  not 
every  case  of  tuberculosis  which  has  been  aggravated  by  preg- 
nancy can  be  arrested  in  its  unfavourable  course  by  the  induction 
of  abortion. 

The  operation  is  least  justified  in  those  advanced  cases  the 
prognosis  of  which  may  be  regarded  as  hopeless — with  or  with- 
out pregnancy — and  where  we  can  hardly  expect  to  prolong  the 
life  of  the  patient,  but  where  there  is  on  the  other  hand  a  chance 
of  a  living  child  being  eventually  born.  The  fear  of  Mara- 
gliano  and  Hamburger,  which  is  not  always  justified,  that  a 
further  tuberculous  unit  will  be  added  to  mankind  would  if 
carried  to  its  logical  conclusion  render  abortion  indicated  in 
those  cases  also  where  the  father  is  tuberculous. 

The  centra-indication  on  account  of  the  bad  prognosis  must 
apply  to  the  majority  of  the  cases  of  laryngeal  tuberculosis 
(Lohnberg)  ;  because,  although  it  is  proved  that  tuberculosis 
of  the  larynx  may  in  rare  cases  occur  primarily  and  be 
cured,  yet  as  a  rule  it  is  secondary  and  present  in  very  severe 
pulmonary  affections  only.  For  this  reason  Lohnberg  is  quite 
right  when  he  maintains  that  the  restriction  to  exclude  all  hope- 
less cases  must  unfortunately  embrace  almost  entirely  the  tuber- 
culous diseases  of  the  larynx.  Kuttner' s  recommendation  will 
therefore  but  very  seldom  be  acted  upon  in  practice. 

The  operation  may  be  carried  out  only  in  such  cases  where 


396  HEALTH,  DISEASE,  MARRIAGE 

judging  from  our  knowledge  of  tuberculosis  there  is  a  possibility 
that  the  disease  may  be  cured  or  an  improvement  obtained 
which  will  certainly  last  for  years.  If  in  the  course  of  such 
cases  pregnancy  supervenes,  and  a  marked  aggravation  of  the 
pulmonary  disturbance  or  in  the  general  condition  becomes 
apparent  which  is  the  direct  consequence  of  the  pregnancy  only, 
the  question  of  the  induction  of  artificial  abortion  may  arise 
as  a  possible  therapeutic  measure;  likewise  if  in  the  course  of 
a  pregnancy  the  first  symptoms  of  tuberculosis  make  their 
appearance,  or  if  haemoptysis,  metastatic  tuberculosis  or  pleurisy 
occurs.  Especial  regard  must  always  be  paid  to  the  physical 
condition  of  the  patient,  or  as  v.  Leyden  calls  it,  to  her  "dis- 
position." It  is  therefore  understood  that  we  are  not  under 
any  circumstances  obliged  to  induce  abortion  in  tuberculous 
pregnant  women.  This  important  question  cannot,  as  Mara- 
gliano  desires,  be  answered  generally,  but  must  be  decided 
individually  in  each  separate  case.  We  must  however  always 
remember  that  the  possible  help  thus  rendered  to  the  mother 
is  dearly  bought,  bought  at  the  cost  of  a  future  human  life, 
and  that  the  sacrifice  should  at  least  be  compensated  for  by 
a  substantial  gain  to  the  mother. 

Artificial  premature  labour.— The  second  possi- 
bility at  our  command,  namely  the  interruption  of  the  pregnancy 
by  the  induction  of  artificial  premature  labour,  is  an  interference 
which  is  justified  on  the  rarest  occasions  only.  The  dangers  of 
pregnancy  in  tuberculous  women  are  greater,  the  complications 
more  frequent  and  the  suffering  of  the  patients  more  severe 
during  the  first  months  of  the  pregnancy  than  during  the  last, 
and  rapid  aggravations  are  to  be  feared  only  from  the  moment 
labour-pains  set  in  until  the  end  of  the  puerperal  state.  What 
Gusserow  has  rightly  pointed  out  with  respect  to  pregnant 
women  suffering  from  heart  disease,  namely  that  the  danger  of 
labour  diminishes  in  proportion  to  the  rapidity  of  the  labour 
act,  applies  equally  in  the  case  of  those  suffering  from  tubercu- 
losis. The  induction  of  premature  labour  is  an  uncommonly 
difficult  operative  interference,  the  consequences  of  which  to 
the  whole  organism  are  not  to  be  compared  with  those  of  arti- 
ficial abortion.  The  pains  are  exceedingly  weak,  the  delivery 


DISEASES  OF  THE  RESPIRATORY  ORGANS     397 

lasts  much  longer  than  in  normal  labour,  often  several  days,  and 
for  this  reason  artificial  premature  labour  causes  in  90  cases 
out  of  100,  as  Gusserow  also  truly  says,  a  much  severer  task 
and  consequently  a  much  greater  danger  than  normal  child- 
birth. 

With  the  idea  to  help  the  mother,  the  induction  of  prema- 
ture labour  is  therefore  never  to  be  recommended.  The  possi- 
bility of  its  indication  exists  only  where  the  debility  of  the 
mother  becomes  rapidly  so  much  worse,  that  her  death  is  likely 
to  occur  before  the  normal  end  of  the  pregnancy  and  that  the  life 
of  the  child  can  only  be  saved  by  the  artificial  interference. 

Prevention  of  conception  by  tuberculous 
women.  —  If  we  bear  in  mind  the  dangers  which  tuberculous 
women  incur  by  becoming  pregnant,  and  the  narrow  limits 
within  which  we  may  resort  to  artificial  abortion;  if  we  recollect 
the  fact  that  although  the  operation  is  in  many  cases  likely  to 
be  successful^  we  can  never  foretell  the  success  with  certainty, 
it  will  be  regarded  as  one  of  the  principal  duties  of  the  physician 
to  endeavour  by  all  the  possible  means  at  his  disposal  to  prevent 
the  conception  of  tuberculous  women.  (In  another  chapter  of 
this  work  will  be  found  a  dissertation  on  the  utility  of  these 
preventive  means.)  The  justification  of  their  application  does 
not  lie  in  the  intention  to  prevent  the  propagation  of  tuberculous 
individuals  as  "future  tuberculous  units,"  but  exclusively  in  the 
attempt  to  save  the  tuberculous  woman  from  the  dangers  with 
which  she  is  threatened  in  consequence  of  conception. 

Prohibition  of  lactation  by  tuberculous  wo= 
men. — There  remains  yet  to  be  mentioned  that  in  numerous 
cases  where  tuberculous  women  have  had  normal  labours,  the 
lactation  is  to  be  strictly  prohibited,  whether  the  pregnancy  and 
childbirth  have  been  well  borne  or  not.  Moreover,  seeing  that 
lactation  makes  great  demands  upon  the  whole  organism,  it  is 
necessary  to  forbid  it  even  in  such  cases  where  the  diagnosis  is 
not  absolutely  certain  and  where  there  is  only  a  suspicion  that 
the  mother  is  predisposed  to  tuberculosis.  It  is  equally  necessary 
to  wean  the  child  immediately,  where  the  mother  commences 
to  show  tuberculous  symptoms  in  the  course  of  the  lactation- 
period. 


398  HEALTH,  DISEASE,  MARRIAGE 

2.  Bronchial  Asthma. 

Next  to  tuberculosis  bronchial  asthma  is  of  the  chronic 
diseases  of  the  respiratory  organs  the  one  which  deserves  per- 
haps the  greatest  amount  of  consideration  from  the  point  of 
view  of  those  who  are  about  to  contract  marriage.  Not,  of 
course,  to  the  same  extent  as  tuberculosis,  since  all  those  factors 
which  are  of  such  enormous  importance  to  the  whole  of  man- 
kind where  the  question  of  marriage  arises  in  connection  with 
tuberculous  persons  are  absent  in  asthma,  a  disease  which  is, 
by  the  way,  relatively  very  prevalent.  For  the  bronchial  asthma 
of  the  husband  or  wife  causes  no  danger  to  the  other  partner, 
but  at  the  outside  a  certain  amount  of  inconvenience  and 
discomfort.  Nor  is  the  opinion  of  some  authors  that  the  disease 
is  particularly  often  inherited  sufficiently  proved  by  statistics, 
or  generally  shared.  It  is  true  that  Salter1  has  been  able  to 
demonstrate  heredity  in  40%  of  his  cases,  but  Berkart*  could 
not  do  so  in  more  than  about  16%  of  all  those  which  he  has 
observed.  At  any  rate  the  number  of  cases  upon  which  both 
these  statistics  are  based  is  too  small  to  permit  a  decisive  conclu- 
sion with  regard  to  the  theory  of  the  hereditary  character  of 
asthma  to  be  drawn  from  them.  The  fact  that  the  disease  is 
occasionally  present  both  in  the  parents  and  in  one  of  their 
children  does  not  justify  its  inclusion  among  the  genuine  heredi- 
tary diseases.  On  the  other  hand  A .  Frankel3  points  out  that 
the  family  predisposition  need  not  necessarily  manifest  itself 
in  such  a  manner  that  the  parents  particularly  suffered  from 
asthma;  but  different  brothers  and  sisters  may  exhibit  the 
disease  and  yet  the  parents  may  have  been  always  free  from  it. 

There  is  consequently  more  reason  to  attribute  the  common 
disease  to  some  common  cause  as  f.  i.  rickets  during  childhood, 
which  has  very  often  been  accused  in  this  connection.  But  this 
is  also  an  hypothesis  which  has  very  little  in  its  favour,  seeing 
how  difficult  it  is  to  bring  it  into  agreement  with  the  general 
view  prevalent  at  the  present  day  that  bronchial  asthma  is  a 
reflex  neurosis. 


'The  Asthma.  London  1860. 

'The  Bronchial  Asthma.  London  1883. 

'Spec.  Pathologic  u.  Ther.  d.  Lung.  Vol.  II,  Berlin  1902. 


DISEASES  OF  THE  RESPIRATORY  ORGANS     399 

Only  by  holding  this  opinion  it  is  possible  to  obtain  a  uni- 
form notion  with  regard  to  the  collection  of  symptoms  which 
we  call  bronchial  asthma  and  which  is  the  result  of  so  many 
different  causes.  According  to  Frankel,1  the  peculiar  constitu- 
tion of  the  nervous  system  of  the  sufferer  from  asthma  which 
is  responsible  for  the  predisposition  to  the  disease  is  the  outcome 
of  an  hyperaesthesia  of  the  nervous  regions  which  are  in  imme- 
diate relationship  with  the  respiratory  tract.  Theoretically  it 
ought  to  be  possible  to  say  that  the  more  circumscribed  the 
point  of  excitation  (nose,  uterus)  the  better  the  prognosis  on 
account  of  the  greater  ease  with  which  therapeutic  remedies 
can  be  applied,  and  that  the  prognosis  is  worst  where  we  do  not 
know  the  locality  of  irritation  at  all,  and  where  we  must  sus- 
pect the  cause  of  the  bronchial  spasm  to  lie  in  the  abnormal 
irritability  of  the  bulbar  respiratory  centre. 

But  although  the  simultaneous  occurrence  of  nasal  polypi 
and  bronchial  asthma,  first  demonstrated  by  Foltolini,  and  to 
which  Hack  afterwards  added  diseases  of  the  lower  muscles, 
led  in  a  number  of  cases  to  a  cure  of  the  asthma  by  local  treat- 
ment, this  success  was  not  achieved  in  a  perhaps  far  greater 
number  of  cases. 

It  is  therefore,  to  say  the  least,  very  uncertain  whether  the 
prognosis  of  such  cases  of  asthma  which  rest  upon  abnormalities 
of  the  nasal  mucous  membrane  may  be  declared  particularly 
favourable,  and  this  is  a  circumstance  not  without  importance 
with  reference  to  the  question  of  consent  to  marriage. 

Neither  does  the  better  defined  sub-division  of  the  disease 
from  the  standpoint  of  prognosis,  as  suggested  by  some  asthma- 
therapeutists  (Bruggemann)2  offer  any  practical  guide  for  judg- 
ing beforehand  the  course  of  the  disease  and  a  possibility  of 
really  successful  treatment. 

Consent  to  marriage  in  cases  of  bronchial 
asthma. — For  although  our  knowledge  of  the  genesis  and 
course  of  asthma  is  greatly  increased,  it  cannot  be  denied  that 
our  ability  to  treat  the  disease  otherwise  than  symptomatically 
has  with  the  above-mentioned  exceptions  remained  the  same  as 


1A.  Frankel,  1.  c. 

*Das  Asthma.    Wiesbaden  1901. 


400  HEALTH,  DISEASE,  MARRIAGE 

before.  And  if  in  a  few  cases  there  has  been  a  spontaneous 
cure,  asthma  must  on  the  whole  be  included  among  the  incurable 
diseases.  The  disease  extends,  however,  over  such  a  long 
period  of  time,  and  the  duration  of  life  in  those  suffering  from 
bronchial  asthma  is  by  so  little  different  from  what  it  is  under 
normal  circumstances,  that  it  can  hardly  always  be  regarded 
either  in  the  man  or  in  the  woman  as  a  decided  impediment  to 
marriage.  The  case  is  however  different  where  the  usual  results 
of  long-standing  asthma  and  of  frequent  attacks,  such  as  severe 
emphysema,  hypertrophy  and  dilatation  of  the  right  ventricle, 
tricuspid  regurgitation  or  renal-disorders,  have  made  their 
appearance.  The  frequency  of  the  attacks  is  also  of  decisive 
prognostic  importance;  for  although  death  very  seldom  ensues 
during  an  attack,  it  must  be  taken  for  granted  that  the  longer 
the  interval  between  two  successive  attacks,  the  slower  the  rate 
at  which  changes  in  the  lungs  and  in  the  heart  take  place.  It 
is  also,  perhaps,  worth  mentioning  that  the  kind  of  "asthmatic 
diseases"  which  are  to  be  regarded  almost  exclusively  as  idio- 
syncrasies, that  is,  which  appear  only  in  consequence  of  certain 
conditions  (climatic  injuries,  hay-fever)  can  never  form  a  con- 
tra-indication  in  the  contraction  of  marriage,  since  the  causative 
factors  can  easily  be  avoided. 

Sexual  intercourse  and  pregnancy  in  bron- 
chial asthma. —  As  regards  the  bronchial  asthma  of  young 
girls,  there  have  been  several  cases  observed  where  marriage 
had  a  beneficial  effect. 

Thus  Peyer1  mentions  the  case  of  a  girl  who  was  asthmatic, 
who  married,  became  pregnant  and  gave  birth  to  a  healthy 
child.  During  the  time  of  pregnancy  she  was  absolutely  and 
perfectly  well.  Later  on,  the  attacks  appeared  again,  and  were 
removed  by  local  treatment  of  the  uterus.  The  writer  has  also 
seen  a  striking  case  of  improvement  in  an  asthmatic  young  mar- 
ried woman.  Before  her  marriage  the  attacks  used  to  occur  on 
an  average  every  4  weeks;  after  she  was  married  the  number  of 
the  attacks  diminished  so  considerably  that  there  were  often 
intervals  of  6  months  and  longer  between  any  two  of  them. 

This  phenomenon  is  probably  associated  with  the  exercise 


Berliner  Klinik.  14. 


DISEASES  OF  THE  RESPIRATORY  ORGANS    401 

of  the  sexual  function,  as  we  must  assume  that  by  the  gratifica- 
tion of  the  desire  there  is  caused  a  reduction  in  the  general 
irritability  of  the  nervous  system  and  consequently  also  in  that 
of  the  nervous  tracts  connected  with  the  attacks. 

There  have  only  been  very  few  communications  made  on  the 
course  of  pregnancy  in  asthmatic  women,  which  may  probably 
be  accounted  for,  by  the  fact  that  no  peculiarities  or  complica- 
tions have  been  noticed.  For  this  reason  it  is  perhaps  advisable 
that  I  should  mention  the  case  of  an  asthmatic  female  out- 
patient in  whom  I  observed  an  especially  great  inclination  to 
miscarriages,  all  of  which  happened  after  asthmatic  attacks 
and  which  were  probably  in  close  causal  relation  to  the  latter. 

The  question  may  also  crop  up  occasionally  whether  the 
presence  of  bronchial  asthma  justifies  recourse  to  artificial  abor- 
tion. 

Generally  speaking,  the  necessity  for  this  will,  in  view  of  the 
nature  and  prognosis  of  the  affection  seldom  arise.  The  opera- 
tion will  have  to  be  performed  only  where  in  the  course  of 
the  pregnancy  the  attacks  are  so  frequent  and  of  such  long  dura- 
tion that  the  life  of  the  mother  is  in  danger.  This  is  however 
likely  to  happen  but  in  rare  instances. 

The  question  whether  asthmatic  mothers  should  be  per- 
mitted to  suckle  their  infants  is  also  not  likely  to  form  very  often 
a  subject  of  doubtful  consideration.  For  although  special 
influences  on  the  course  and  severity  of  the  disease  are  hardly 
ever  likely  to  be  noticed,  it  is  nevertheless  advisable  as  a  rule  to 
recommend  sufferers  from  asthma  to  refrain  from  lactation  since 
the  secretion  of  milk  must  exercise  a  debilitating  effect  upon 
their  organism. 

3.    Emphysema. 

The  significance  of  the  remaining  chronic  diseases  of  the 
lungs  with  regard  to  the  married  state  is  to  a  certain  extent  a 
limited  one.  A  large  number  of  them,  such  as  malignant 
tumours  of  the  lung,  larynx  and  mediastinum  (carcinoma,  sar- 
coma) have,  where  they  can  be  diagnosed,  such  an  absolutely 
bad  prognosis  that  the  question  whether  an  individual  affected 
with  one  of  them  should  be  permitted  to  marry  or  not  is  not 


402  HEALTH,  DISEASE,  MARRIAGE 

likely  to  give  rise  to  any  discussion  at  all;  with  regard  to  others, 
such  as  actinomycosis,  echinococcus,  syphilis  of  lung,  etc.,  there 
does  not  seem  any  necessity  to  dwell  on  the  point,  partly  for 
the  above-mentioned  reasons,  and  partly  also  because  these 
diseases  are  so  infrequent  that  they  may  well  be  designated  as 
clinical  rarities.  With  regard  to  the  rest  of  the  pulmonary  and 
laryngeal  diseases  we  may  generally  say  that  though  they  are 
relatively  very  prevalent,  they  diminish  but  very  little  the  life- 
duration  of  those  who  are  subject  to  them,  and  do  not  very 
materially  lower  the  activity  and  working  ability  of  the  patients. 
Some  of  the  affections  finally  commence  fortunately — at  least 
as  a  rule — at  a  time  of  life  when  the  contraction  of  marriage 
is  only  exceptionally  thought  of. 

A  somewhat  more  detailed  consideration  however  seems 
indicated  with  respect  to  emphysema.  As  to  the  genesis  of 
emphysema  opinion  does  not  appear  as  yet  to  be  unanimous. 
Only  that  much  is  certain,  that  emphysema  is  occasionally, 
though  not  very  frequently,  observed  at  an  early  age,  and  that 
it  is  not  always  a  consequence  of  chronic  bronchitis.  And  more- 
over as  the  disease  appears  sometimes  in  young  persons  as  a 
result  of  occupational  injuries  (blowers)  the  physician  may 
have  the  question  addressed  to  him  whether  an  individual  suffer- 
ing from  emphysema  should  be  allowed  to  marry  or  not.  The 
answer  must  undoubtedly  be  in  the  affirmative;  for  although 
a  man  subject  to  emphysema  cannot  on  account  of  his  dyspnoea 
be  regarded  exactly  as  an  ideal  husband  his  working  ability 
is  nevertheless  not  materially  diminished  and  his  probable  expec- 
tation of  life,  should  no  secondary  symptoms  appear,  is  only 
slightly  shortened.  But  where  the  consequential  results  of 
emphysema  which  are  practically  the  same  as  those  of  bronchial 
asthma  have  already  made  their  appearance,  marriage  will 
probably  have  to  be  opposed  in  the  generality  of  cases. 

Emphysema  is  far  more  rarely  present  in  women  than  in 
men  and  this  fact  as  well  as  the  circumstance  that  peculiarities 
are  hardly  likely  to  occur,  explain  how  it  is  that  there  are  no 
detailed  contributions  to  literature  on  the  course  of  pregnancy, 
labour  and  childbed  of  emphysematic  women.  It  is,  however, 
to  be  presumed  that  the  shortness  of  breath  is  in  pregnant 


DISEASES  OF  THE  RESPIRATORY  ORGANS    403 

women  as  a  rule  considerably  aggravated  by  the  high  position 
of  the  diaphragm  and  that  the  sequelae  of  emphysema  may  thus 
possibly  be  hastened.  For  this  reason  it  does  not  exactly  appear 
desirable  that  emphysematic  women  should  become  pregnant, 
but  on  the  other  hand  the  danger  is  not  so  great  as  to  justify 
the  adoption  of  anti-conceptional  remedies  or  the  artificial  inter- 
ruption of  existing  pregnancy.  Lactation  on  the  part  of 
emphysematic  women  may  also  unhesitatingly  be  permitted, 
though  there  may  be  special  cases  where  it  is  contra-indicated. 

4.   Chronic  Diseases  of  the  Bronchi. 

Chronic  bronchitis. —  Chronic  bronchitis  is  also  to  be 
regarded  as  a  relatively  harmless  complaint.  The  often 
repeated  assertion  that  ordinary  bronchitis  may  turn  into  tuber- 
culosis is  not  scientifically  proved,  and  such  a  transition  is  very 
seldom  seen  in  practice.  Chronic  bronchitis  has  no  influence  in 
shortening  the  life  of  those  subject  to  it,  and  cannot  therefore 
be  looked  upon  as  an  indication  against  marriage.  Nor  has 
ordinary  bronchial  catarrh  any  effect  upon  pregnancy.  Fellner1 
attributes  to  it  only  a  slight  increase  in  the  cyanosis  and  in  the 
dyspnoea  which  is  a  physiological  accompaniment  of  pregnancy. 

Fibrinous  or  plastic  bronchitis  has  probably  on 
account  of  its  prognosis  been  sub-divided  into  an  acute  and 
chronic  form.  In  the  acute,  the  prognosis  is  always  very 
uncertain  and  very  serious  because  of  the  possibility  of  death 
by  suffocation  through  the  fibrin  coagula.  For  this  reason  it 
is  not  advisable  to  give  the  consent  to  marriage  too  soon.  The 
chronic  form  of  fibrinous  bronchitis  has  a  much  better  prognosis. 
It  often  disappears  just  as  quickly  as  it  appears,  without  it 
being  possible  to  find  any  special  causes  for  its  appearance  or 
disappearance.  Thus,  f.  i.,  I  have  been  watching  a  case  for 
the  last  4  years  (minutely  described  by  v.  Raven2  which  has 
been  running  its  course  since  3^2  years  without  any  symptoms 
whatever.  Chronic  fibrinous  bronchitis,  where  it  is  not  to  be 
regarded  as  a  complication  of  other  organic  diseases  (heart 


'Die   Beziehungen   innerer   Krankh.   zu   Schwang.   Geb.    u.   Wochenbett. 
Leipsic- Vienna  1901. 

2Zwei  Falle  von  Bronch.  fibrin.  Dissert.  Berlin  1902. 


404 

disease,  tuberculosis)  will  therefore  in  the  generality  of  cases 
not  form  an  obstacle  to  marriage. 

Foetid  bronchiectasis  and  bronchitis. — As  re- 
gards, finally,  those  diseases  of  the  respiratory  organs  the  princi- 
pal feature  of  which  consists  of  a  more  or  less  marked  foetor  of 
the  breath,  such  as  foetid  purulent  bronchitis,  the  saccular, 
cylindrical  and  multiple  forms  of  bronchiectasis,  this  defect 
alone  is  sufficient  to  cause  some  hesitation  in  the  granting  of  the 
permission  to  marry,  since  it  must  prove  a  constant  source  of 
disgust  to  the  married  partner  living  in  close  intimacy  with  a 
person  thus  affected.  For  this  reason  and  from  the  fact  that 
the  prognosis  of  this  disease  is  an  exceedingly  serious  one  (much 
more  serious  in  bronchiectasis  than  in  purulent  bronchitis,  which 
may  occasionally  terminate  in  recovery)  we  may  draw  the  con- 
clusion that  individuals  suffering  from  these  diseases  of  the 
respiratory  organs  must  be  energetically  advised  not  to  marry. 


XII 

Diseases    of    the    Organs    of    Digestion    in 
Relation    to    Marriage 


XII 


DISEASES  OF  THE  ORGANS  OF  DIGESTION 
IN  RELATION  TO  MARRIAGE 

By  Professor  C.  A.  Ewald  (Berlin) 

If  we  consider  the  reciprocal  relations  between  marriage  and 
the  functions  or  disturbances  of  the  digestive  organs  from  the 
medical  point  of  view  we  find  that  the  gain  which  accrues  to  the 
organism  from  this  union  is  undoubtedly  like  in  so  many  other 
respects  greater  in  the  case  of  the  male  sex,  and  that  the  poor 
wife  derives  from  the  married  state  a  plenteous  harvest  of  ill- 
health.  The  salubrious  advantages  which  marriage  brings  to 
her  are  decidedly  outweighed  by  the  disadvantages.  For  this 
reason  the  greater  part  of  the  following  remarks  will  be  taken 
up  by  diseases  which  affect  the  female  married  partner. 

In  point  of  fact  the  above  statement  hardly  requires  any 
proof ;  the  latter  will  doubtless  become  evident  from  the  subse- 
quent observations. 

Beginning  first  with  that  which  is  common  to  both  husband 
and  wife,  it  is  clear  that  the  gain  which  an  harmonious  and 
happy  marriage  must  bring  to  both  of  them  generally,  and  in 
respect  of  the  digestive  functions  in  particular,  is  so  obvious  that 
it  is  not  necessary  to  waste  any  words  about  it.  Psychical  and 
physical  well-being  towards  which  a  well-regulated  sexual  inter- 
course contributes  a  by  no  means  unimportant  share  co-operates 
in  influencing  favourably  the  course  of  the  vegetative  functions, 
and  in  especial  those  of  the  digestive  organs.  It  is  only  after 
they  are  married  and  free  from  the  dull  oppression  and  unsatis- 
fied longing  of  bachelor-life  that  many  men  begin  to  understand 
what  it  means  to  be  healthy  in  body  and  healthy  in  mind. 

On  the  other  hand,  the  disturbances  of  digestion  which  we 


4o8  HEALTH,  DISEASE,  MARRIAGE 

must  attribute  to  married  life  are  partly  of  an  indirect  and 
partly  of  a  direct  character. 

Disturbances  of  digestion  through  psychical 
factors. — To  this  category  belong  all  those  factors  which 
influence  the  soul  directly  and  the  digestive  tract  only  indirectly, 
and  which  are  called  forth  by  the  troubles  and  perturba- 
tions connected  with  the  married  state.  Naturally  this  refers 
to  the  husband  no  less  than  to  the  wife. 

Nervous  complaints. —  The  struggle  for  existence  and 
the  maintenance  of  the  children,  illness  in  the  family  and  other 
anxious  cares  react  in  many  individuals  on  the  digestive  appa- 
ratus and  produce  the  most  various  disturbances  in  the  same. 
This  is  ancient  wisdom,  and  Shakespeare  knew  what  he  was 
saying  when  he  makes  Henry  VIII  pronounce  sentence  of  death 
on  Cardinal  Wolsey  by  the  words:  "Read  over  this,  and  after 
this:  and  then  to  breakfast,  with  what  appetite  you  have." 
These  disturbances  may  affect  all  parts  of  the  digestive  tract, 
from  the  mouth  down  to  the  large  intestine  and  anus,  and  mani- 
fest themselves  by  most  variable  so-called  nervous  complaints. 
There  are  people  who  when  they  are  troubled  or  excited  cannot 
"swallow  a  bite,"  not  because  the  mechanism  of  deglutition  is 
out  of  order,  but  because  the  secretion  of  saliva  is  insufficient 
and  the  food-boli  are  consequently  not  rendered  slippery  enough 
to  be  gulped  down  the  entrance  into  the  oesophagus,  so  that  they 
"stick  in  the  throat."  In  others  there  occur  conditions  of 
depression  in  the  secretory  and  motor  functions  of  the  gastro- 
L  intestinal  canal.  If  the  gastric  juice  is  examined  in  such  cases, 
the  analysis  shows  a  diminished  amount  of  HCL  and  of  pepsine, 
often  associated  with  the  characteristic  symptoms  of  motor 
weakness  or  of  atony  of  the  muscular  walls  of  the  stomach. 
This  applies  also  to  the  intestines.  Tendency  to  flatulence,  con- 
stipation or  an  irregular  action  of  the  bowels  accompanied  by 
intercurrent  pseudo-diarrhoeic  evacuations  are  the  most  promi- 
nent symptoms.  I  have  never  yet  under  such  conditions  noticed 
an  inclination  to  an  increased  action  of  the  stomach,  say  in  the 
form  of  hyperchlorhydria,  or  gastrosuccorrhoea,  etc.  This 
might  possibly  be  said  to  be  the  case  with  the  intestines  which 
show  occasionally  a  tendency  to  increased  peristalsis  or  better 


DISEASES  OF  THE  ORGANS  OF  DIGESTION    409 

said  to  more  frequent  evacuations.  But  this  occurrence  also 
is  perhaps  due  to  a  weakness  of  the  large  intestine  rather  than 
to  an  increased  function  of  the  small  intestines.  What  part  is 
played  in  these  disturbances  by  an  altered  activity  of  the  liver 
is  for  the  present  entirely  beyond  our  knowledge. 

But  in  other  directions  as  well,  married  life  is  capable  of 
producing  all  kinds  of  injury  to  the  digestive  functions.  I 
allude  to  the  nervous  disorders  which  arise  from  an  excessive 
sexual  intercourse  or  from  an  abnormal  performance  of  the 
sexual  act.  Both  are  more  frequent  than  one  would  imagine 
and  we  hear  occasionally  most  incredible  confessions  in  this 
respect.  There  is  no  necessity  to  enlarge  on  this  point  which 
has  already  been  discussed  in  a  previous  chapter  (see  Article 
by  Fiirbringer)  of  this  work,  but  I  wish  to  point  out  that  it  is 
the  various  forms  of  the  preventive  mode  of  intercourse  which 
most  pre-eminently  seem  to  occasion  nervous  reflexes  upon  the 
digestive  tract.  Probably  more  for  moral  than  physical  reasons, 
but  possibly  also  because  newly  married  people  in  particular  are 
apt  when  practising  preventive  intercourse  to  disregard  the 
natural  abstinence  imposed  by  pregnancy  and  parturition,  and 
thus  to  create  a  constant  irritability  of  the  nerves  constituting 
the  pudendal  plexus  and  also  of  the  nervous  system  generally. 
One  might  retort  against  this  that  in  sterile  marriages  there 
is  also  no  "close-time"  and  yet  they  do  not  show  any  particular 
predominance  of  nervous  and  especially  nervous-dyspeptic  con- 
ditions. I  have  however  frequently  been  assured  by  gynaecol- 
ogists that  in  precisely  this  sort  of  marriages,  a  certain  sexual 
frigidity  often  appears  very  early  which  excludes  the  possibility 
of  sexual  over-indulgence.  However  that  may  be,  there  is  no 
doubt  that  we  see  cases  by  the  hundred  in  which  the  beginning 
and  progress  of  nervous  gastro-intestinal  disorders  may  be 
traced  to  this  source.  It  is  only  natural  that  we  should  meet 
it  oftener  in  men  than  in  women,  since  the  latter  do  not  alto- 
gether experience  as  a  rule  such  severe  perturbations  of  the 
nervous  system  from  the  exercise  of  the  sexual  act  as  the  former. 

i.  Diseases  of  the  Stomach  and  Intestines. 
We  know  nothing  certain  about  a  direct  infection  or  trans- 


4io  HEALTH,  DISEASE,  MARRIAGE 

mission  of  an  organic  disease  of  the  digestive  apparatus  from 
husband  to  wife  or  vice-versa.  All  that  we  might  perhaps  have 
to  consider  in  this  connection  are  cancerous  and  possibly  also 
tuberculous  affections  which  may  appear  in  the  course  of  the 
gastro-intestinal  tract.  Cases  have  repeatedly  been  observed  of 
husband  and  wife  who  have  been  attacked  in  quick  succession 
by  cancer  of  the  stomach  or  of  the  intestines;  but  whether  we 
should  in  such  cases  admit  a  direct  transmission  of  the  disease 
through  the  common  use  of  utensils,  such  as  spoons,  forks, 
knives,  cups  and  plates,  etc.,  is,  on  account  of  the  incomplete 
knowledge  we  possess  on  the  etiology  of  cancer,  impossible  to 
say. 

Influence  of  marriage  on  the  digestive  func- 
tions of  the  husband. — As  regards  the  sterner  sex,  it  is 
unquestionable  that  marriage  is  in  the  case  of  many  young  men 
a  beneficial  change  from  their  bachelor-life  and  the  deficient 
and  irregular  meals  often  associated  with  it  and  no  less  often 
compensated  for  by  excessive  drinking.  The  possession  of  a 
well-regulated  home  of  one's  own  brings  as  a  rule  to  the  abused 
and  over-irritated  gastro-intestinal  apparatus  careful  and  suit- 
able nourishment  and  attention.  The  provision  of  suitable 
food  and  especially  of  food  for  invalids,  is  indeed  often  a 
serious  difficulty  in  the  case  of  bachelors  who  have  not  their 
own  household,  particularly  in  small  towns,  although  philan- 
thropic societies  have  recently  been  formed  f.  i.  in  Berlin,  to 
supply  the  deficiency  to  a  certain  extent  by  the  establishment  of 
public  kitchens  for  invalids  which  distribute  proper  food  in  the 
various  parts  of  the  town.  In  some  places  proprietors  of 
restaurants  are  also  prepared  to  supply  the  requisite  dietary 
articles  according  to  prescription.  But  on  the  whole,  these 
arrangements  do  not  apply  to  the  vast  majority  of  men,  and 
it  is  the  married  state  in  which  most  bachelors  hope  to  find  the 
food  suited  for  their  individual  cases. 


Translator's  note:  The  author  has  evidently  forgotten  to  add  that  the 
same  cause  may  have  operated  in  producing  cancer  in  both  the  husband  and 
the  wife,  seeing  that  they  are  constantly  exposed  to  the  same  injurious  influ- 
ences, and  that  infection  from  person  to  person  may  have  nothing  to  do  with 
the  matter. 


DISEASES  OF  THE  ORGANS  OF  DIGESTION     411 

It  is  not  only  invalids,  however,  who  derive  benefit  from 
marriage;  the  well-regulated  mode  of  life  with  its  regular  and 
uniform  meals  usually  associated  with  the  married  state  is  to 
healthy  husbands  also  an  advantage  by  no  means  to  be  despised. 
To  this  we  may  add  that  a  considerable  number  of  men,  from 
a  sense  of  the  responsibility  involved  by  the  creation  of  a  house- 
hold, abstain  from  a  number  of  extravagances  which  would 
otherwise  undoubtedly  cause  gastric  and  intestinal  troubles. 
This  is  so  self-evident  that  we  can  dismiss  the  subject  with  these 
few  words. 

These  advantages  are  counterbalanced  by  the  few  incon- 
veniences or  disturbances  which  arise  to  the  husband  from  the 
married  state  and  which  have  already  been  enumerated  above. 

Influence  of  marriage  on  the  digestive  func- 
tions of  the  wife. — The  special  effects  which  married  life 
exerts  on  the  digestive  apparatus  of  the  wife  are  connected  in 
the  first  instance  with  the  functions  of  the  generative  organs, 
especially  with  pregnancy,  childbed  and  its  results.  These 
form  the  principal  source  of  many  troubles  but  rarely  that  of 
any  benefit  to  health  which  accrue  to  the  wife  from  the  married 
state. 

Influence  of  pregnancy  and  puerperium. —  If 
we  follow  the  course  of  the  digestive  tract  from  the  mouth 
down  to  the  anus  we  find  everywhere  the  influences  of  the 
generation-processes  marked  out  sometimes  lightly  and  some- 
times strongly,  sometimes  temporarily  and  sometimes  perma- 
nently. And  it  is  not  only  the  digestive  canal  proper,  but  also 
its  adnexa,  and  above  all  the  liver  which  are  affected.  We 
should  really  have  to  give  here  the  pathology  of  pregnancy  and 
child-bed,  did  we  wish  to  include  a  detailed  description  of  all 
the  conditions  which  present  themselves  in  this  connection — and 
this,  we  do  not  consider,  that  we  are  called  upon  to  do.  We 
cannot  however  omit  a  brief  examination  of  them. 

The  mouth. — Beginning  with  the  oral  cavity  we  have  to 
mention  first  of  all  one  of  the  most  frequent  of  its  affections 
which  occur  during  pregnancy,  namely  toothache,  and  its  fre- 
quent companion,  carious  disease  and  destruction  of  the  teeth, 
which  however  appear  sometimes  without  toothache  and  which 


4i2  HEALTH,  DISEASE,  MARRIAGE 

lead  in  time  to  the  loss  of  the  teeth.  Hence  the  well-known 
saying,  that  each  child  costs  its  mother  at  least  one  tooth.  Asso- 
ciated with  this  are  inflammatory  processes  at  the  gums  (gingi- 
vitis, hypertrophia  gingivarum)  and  haemorrhage  from  the 
same;  and  a  fairly  frequent  occurrence  is  also  a  general  hyper- 
aemia  of  the  buccal  mucous  membrane  which  manifests  itself 
by  redness,  swelling  and  a  tendency  to  haemorrhages.  As  to  the 
cause  of  these  conditions  we  cannot  say  anything  definite.  Like 
in  so  many  other  disturbances  which  we  come  across,  some 
authors  assume  a  reflex  process  emanating  from  the  uterus,  an 
explanation  by  which,  as  Kehrer  rightly  says  we  only  hide  insuf- 
ficiently our  ignorance  of  the  internal  physiological  processes, 
whilst  others  see  a  direct  cause  in  the  altered  reaction  of  the 
saliva  during  the  time  of  pregnancy.  An  observation  by 
Galippe,1  so  far  not  supported  by  others,  has  shown  that  the 
saliva  of  pregnant  women  becomes  acid  in  reaction,  loses  its 
quantity  of  ptyalin,  and  favours  for  these  reasons  perhaps  the 
development  of  micro-organisms  which  act  destructively  on 
the  teeth.  Others,  again,  believe  that  the  maternal  organism 
is  called  upon  to  supply  calcium  salts  out  of  bones  and  teeth 
for  the  benefit  of  the  foetal  skeleton,2  in  which  case  it  is  rather 
surprising  that  the  teeth  should  be  attacked  in  the  first  instance, 
and  so  severely,  too,  whilst  the  other  bones — if  we  do  not  take 
into  account  the  rare  cases  of  osteomalacia — remain  quite 
unaffected.  This  would  also  not  explain  how  it  is  that  as  a 
rule  only  such  teeth  are  attacked  which  were  already  diseased 
previous  to  the  pregnancy,  and  why  women  with  sound  teeth 
which  they  are  in  the  habit  of  keeping  scrupulously  clean  escape 
as  a  rule  altogether.  And  though  we  can  understand  the  reason 
of  the  toothache  as  a  symptom  of  dental  caries  which  has 
reached  to  the  pulp,  how  about  the  local  hyperaemia,  and  how 
can  we  explain  the  vomiting  of  pregnancy  which  we  shall  con- 
sider later  on?  With  regard  to  these  and  other  phenomena, 
there  really  remains  nothing  for  the  present  but  to  admit  a 


lGalippe,  Influence  of  the  Sex  on  the  Resistance  of  the  Teeth.     Gaz.  d. 
Hopit.  1885.  No.  17. 

*Kirk,  Dental  caries  in  pregnancy.  Philad.  Med.  Times,  1880,  March  27, 


DISEASES  OF  THE  ORGANS  OF  DIGESTION    413 

reflex  action,  notwithstanding  the  taunt  of  Kehrer,  the  justice 
of  which  we  must  recognise. 

It  may  however  be  perhaps  of  some  interest  and  helpful 
in  understanding  the  rationale  of  these  reflexes  if  we  reproduce 
here  a  diagram  by  Eisenhardt1  of  the  nerve-branches  in  the 
abdominal  cavity,  which  shows  at  a  glance  the  course  of  the 
nerves  proceeding  from  the  genital  organs. 

Ptyalism. —  Among  the  reflex  neuroses  is  also  included 
ptyalism,  or  salivation,  which  comes  principally  from  the  sub- 
maxillary  glands,  but  also  from  the  parotid.  The  secreted 
saliva  attains  sometimes  enormous  quantities  and  may  amount 
to  as  much  as  2  litres  in  the  24  hours.  It  is  said  that  this  saliva 
does  not  contain  either  ptyalin  or  sodium  salts.  As  to  ptyalin 
I  am  in  a  position  to  affirm  the  contrary.  I  have  years  ago 
made  numerous  experiments  on  the  ferment  of  the  saliva  and 
occasionally  in  married  women  as  well,  but  strange  to  say  I 
have  never  known  it  to  be  absent,  not  even  in  acute  inflammatory 
conditions  of  the  buccal  cavity. 

As  long  as  there  is  nothing  more  than  ordinary  salivation, 
we  have  before  us  a  disagreeable  but  by  no  means  dangerous 
complication  which  appears  principally  in  the  first  months  of 
pregnancy.  But  when  the  secretion  assumes  great  proportions 
the  swallowed  saliva  produces  occasionally  vomiting  and  the 
salivation  may  become  so  intense  that  the  saliva  runs  from  the 
mouth  in  streams  night  and  day  incessantly,  and  nutrition  suffers 
considerably.  Cases  are  known  where  the  condition  has  led 
to  extreme  prostration  or  even  death.  Under  such  circum- 
stances it  becomes  imperative  to  institute  artificial  abortion, 
especially  as  the  ordinary  remedies  generally  adopted,  such  as 
duboisine,  atropine,  potassium  iodide,  pilocarpine,  are  as  a  rule 
ineffectual.  That  the  conditions  are  probably  reflex  in  origin 
may  be  inferred  from  the  circumstance  that  Lwoff  was  able  to 
obtain  a  rapid  cure  through  the  cauterisation  of  an  erosion  in 
the  cervix  uteri,  and  Audlbert  one  through  the  reposition  of  a 
retroflexed  uterus.  Some  authors  also  regard  ptyalism  as  a 


^Eisenhardt,  Die  Wechselbeziehungen  zwischen  internen  und  gynakolog. 
Erkrankungen.  Stuttgart.  1895. 


DISEASES  OF  THE  ORGANS  OF  DIGESTION    415 

premonitory  sign  of  threatened  eclampsia  but  Fellner1  has  been 
unable  to  find  among  numerous  cases  of  the  latter  disease  one 
single  case  of  ptyalism. 

There  remain  yet  to  be  mentioned  aphthous  stomatitis  and 
glossitis  which  are  occasionally  noticed  during  pregnancy  and 
lactation. 

It  might  be  possible,  as  H.  W .  Freund~  thinks,  to  explain 
all  these  cases  simply  by  assuming  that  the  secretion  of  certain 
substances  from  the  ovaries  into  the  blood  excites  the  salivary 
glands  to  special  activity.  The  physiological  salivation  during 
sexual  excitement  would  seem  to  support  this  theory.  An 
infection  of  the  parotis  through  virulent  bacteria  is,  on  the 
other  hand,  to  be  assumed  in  those  rare  cases,  in  which  an  abscess 
of  the  parotis  has  been  observed  in  connection  with  puerperal 
infection,  which  was,  strange  to  say,  confined  to  the  parotis. 
(Lohlein,  Cure) . 

Vomiting  in  pregnancy. —  Connected  with  this  sub- 
ject is  the  vomiting  in  pregnancy  which,  if  it  occurs  in  excess, 
is  designated  as  hyperemesis.  We  find  this  condition  in  about 
50%  of  all  cases.  Primiparae  and  women  in  the  first  3  months 
of  their  pregnancy  are  most  frequently  affected.  About  half 
the  number  vomit  in  the  morning  only.  The  process  always 
takes  place  easily  and  without  any  special  warning,  the  food 
previously  taken  is  evacuated  and  a  good  appetite  is  soon  after- 
wards re-established.  In  other  cases  however  vomiting  occurs 
also  on  an  empty  stomach.  Pain  is  felt  in  the  epigastrium,  there 
is  a  disinclination  against  food  of  any  kind,  unquenchable 
thirst,  and  a  dry  tongue.  In  such  cases  there  may  result  extreme 
emaciation,  an  anaemic  condition  and  severe  psychical  apathy. 
The  extremities  are  cold,  the  pulse  small,  the  face  appears  hag- 
gard, and  the  whole  condition  makes  a  most  alarming  impres- 
sion. The  more  so  since  in  many  cases  treatment  seems  to  be 


1O.  O.  Fellner,  Die  Beziehungen  innerer  Krankheiten  zu  Schwanger- 
schaft,  Geburt  und  Wochenbett.  Wien  1903  p.  106  ff. 

*H.  W.  Freund,  Die  Beziehungen  der  weiblichen  Geschlechtsorgane  in 
ihren  physiolog.  und  patholog.  Veranderungen  zu  anderen  Organen.  In 
Lubarsch  u.  Ostertag,  Ergebnisse  der  allgem.  Pathologic  u.  patholog.  Anato- 
mic. 3.  Jahrg.  Wiesbaden  1889.  Here  and  in  Fellner's  work,  1.  c.  numerous 
literature  is  quoted. 


4i6  HEALTH,  DISEASE,  MARRIAGE 

altogether  useless.  The  usual  sedatives,  such  as  bromide  of 
potassium,  chloral,  cocaine,  morphia,  administered  internally 
or  hypodermically,  belladonna,  asafcetida — the  favourite  of  an 
old  generation  of  medical  practitioners — sucking  of  ice-pellets, 
and  the  blandest  possible  diet,  lavage  of  the  stomach,  electricity 
and  other  numerous  remedies  are  in  severe  cases  absolutely 
no  good.  Nor  has  local  treatment  as  applied  by  gynaecologists 
in  the  form  of  correction  of  uterine  displacements,  dilatation  of 
the  cervix,  and  similar  other  measures  more  than  a  very  uncer- 
tain beneficial  result — in  most  cases  none  at  all. 

In  two  cases  which  I  saw  and  to  which  I  was  called  in  con- 
sultation in  the  6th  and  yth  month  of  the  pregnancy  respec- 
tively, we  succeeded  by  absolute  deprivation  of  food  by  the 
mouth  and  by  rectal  feeding  which  was  continued  for  5  days  to 
effect  a  cure.  But  whether  we  have  in  such  cases  to  deal  with  a 
genuine  reflex  neurosis,  as  most  authors  suppose,  or  possibly 
with  hysteria  which  is  according  to  Kaltenbach  very  often  the 
cause  of  the  hyperemesis,  must  remain  rather  doubtful.  With 
certainty  we  can  say  that  excessive  vomiting  may  be  the  result 
of  other  factors  as  well,  f.  i.  diseases  of  the  intestines,  kidney, 
liver,  peritoneum,  etc.,  palpable  changes  in  the  uterus  or  finally 
some  gastric  affection  which  has  nothing  to  do  with  the  preg- 
nancy, such  as  dilatation,  carcinoma  and  so  forth.  Very  doubt- 
ful is  however  the  opinion  expressed  by  Condamin1  that  the 
vomiting  is  the  effect  of  a  general  intoxication.  He  treats  it 
accordingly  with  subcutaneous  or  rectal  injections  of  an  artificial 
serum  (?)  with  the  stomach  absolutely  at  rest.  Whether  this  last 
element,  namely  the  rest,  is  in  view  of  my  above-mentioned  two 
cases  the  principal  part  of  the  treatment,  is  at  least  open  to 
discussion  and  not  impossible. 

The  most  radical  and  only  remedy  is  therefore  the  dis- 
burdening of  the  uterus  of  its  contents,  the  embryo.  Where 
abortion  or  premature  labour  is  instituted  on  account  of  the 
severity  of  the  above-discussed  symptoms,  it  is  well  known  that 
in  numerous  cases  an  improvement  takes  place  immediately,  or 
that  the  vomiting  ceases  altogether,  and  the  patients  make  an 


*Condamin,  Note  sur  un  nouveau  traitment  des  vomissements  incoerci- 
bles  de  la  grossesse.    Gazette  d.  Hopit.  1892.  p.  161. 


DISEASES  OF  THE  ORGANS  OF  DIGESTION    417 

extraordinarily  rapid  recovery.  This  happens  also  where  the 
pregnancy  can  be  allowed  to  proceed  uninterruptedly  to  its  natu- 
ral end,  and  it  is  often  astonishing  to  see  with  what  rapidity 
extremely  emaciated  women  regain  their  normal  health.  For 
this  reason  it  is  extremely  difficult  to  fix  the  period  when  under 
such  circumstances  the  pregnancy  should  be  interrupted.  The 
more  so,  as,  strange  to  say,  the  child  does  not  suffer  in  the 
least  by  the  great  weakness  of  the  mother,  and  as  most  extreme 
exhaustion  or  even  the  death  of  the  pregnant  woman  is  more 
likely  to  be  the  result  than  spontaneous  abortion.  Moreover, 
we  must  not  forget  that  the  interruption  of  the  pregnancy  in 
debilitated  women  presents  new  dangers,  for  according  to  a 
tabulation  by  Cohnstein,  out  of  200  cases  treated  by  the  induc- 
tion of  premature  labour,  only  40%  showed  immediate  cure, 
and  i S%  no  improvement  at  all.  In  4%  the  vomiting  grew 
worse,  and  12%  ended  with  death.  At  any  rate,  we  see  that 
hyperemesis  is  under  all  circumstances  a  most  serious  complica- 
tion of  pregnancy. 

Vomiting  may  occur  also  during  parturition;  and  some 
authors  suppose  this  to  be  due  to  a  direct  and  often-repeated 
perturbation  of  the  stomach  caused  by  the  rising  of  the  uterus 
during  labour-pains.  This  seems  to  me  highly  doubtful,  espe- 
cially in  view  of  the  frequent  succussions  to  which  the  stomach 
is  subject  in  certain  occupations,  games,  etc.  I  am  more  inclined 
to  attach  some  importance  to  the  general  contraction  of  the 
abdominal  muscles  which  accompanies  labour  pains. 

Haematemesis  has  also  been  observed,  though  only  very 
rarely.  Fellner1  has  seen  it  occur  in  only  22  cases  out  of 
3800  births.  The  cause  lies  probably  oftenest  in  so-called 
erosions  or  ulcerations  of  the  gastric  mucous  membrane.  That 
severe  vomiting  may  give  rise  to  such  injuries  is  by  no  means 
impossible,  considering  the  intense  violence  exerted  upon  the 
gastric  walls.  Thus  A.  Freund  has  communicated  to  me  a  case 
not  hitherto  published  which  he  has  observed  in  a  primipara 
1 8  years  old  whose  debility  was  extreme  in  consequence  of 
hyperemesis.  The  patient  died  from  exhaustion  before  it  was 


10.  O.  Fellner,  1.  c. 


4i 8  HEALTH,  DISEASE,  MARRIAGE 

possible  to  institute  premature  labour.  The  post-mortem  exam- 
ination revealed  a  fairly  recent  ulcer  of  the  stomach  covered 
with  a  sanguineous  scab  and  extending  deeply  as  far  as  the 
sub-mucous-coat.  The  patient  had  when  alive  shown  nothing 
more  than  streaks  of  blood  in  the  vomit,  and  never  vomited  any 
large  quantity  of  blood.  How  far  the  pregnancy  per  se  exerts 
any  causal  influence  on  such  haemorrhages,  must  be  left  an  open 
question ;  I  am  not  aware  that  they  ever  occur  during  parturition. 

Perforation  of  gastric  ulcers. — A.  Freund  has  seen 
two  cases  of  perforation  of  gastric  ulcers  into  the  peritoneum, 
which  came  on  quite  unexpectedly  and  without  any  warning, 
during  the  first  months  of  pregnancy.  In  the  one  case  the  con- 
tents of  the  stomach  had  sunk  in  the  peritoneal  cavity  as  low 
down  as  Douglas's  pouch,  so  that  the  condition  was  mistaken 
for  a  haematoma  and  an  operation  was  about  to  be  performed. 
The  patient  died  however,  and  the  real  state  of  affairs  became 
apparent  at  the  autopsy.  In  these  cases  also  the  causal  relation- 
ship must  remain  doubtful.  It  was  however  unmistakable  in 
one  case  which  I  have  seen  and  which  is  fully  reported  in  my 
"Klinik  der  Magenkrankheiten."  It  was  the  case  of  a  lady 
belonging  to  the  better  classes  who  took  for  the  purpose  of 
procuring  abortion  several  wine-glassfuls  of  a  hot  concoction 
made  of  red  wine,  chamomile,  thuja  occidentalis  and  other 
herbs,  injecting  afterwards  into  the  vagina  a  hot  mixture  of 
soap  and  water.  She  felt  unwell  the  whole  day,  could  not  eat 
anything,  wanted  to  get  up  in  the  night  and  was  seized  with 
violent  vomiting  of  blood  accompanied  by  syncope.  The  cause 
was  at  the  time  attributed  to  an  ulcer  of  the  stomach,  but  the 
subsequent  event  and  the  lady's  confession  brought  the  true 
explanation. 

Ashton  reports  the  following  case:  On  the  5th  day  after  a 
labour  completed  by  craniotomy  profuse  haematemesis  set  in, 
which  ended  fatally.  The  necropsy  showed  two  ulcers  in  the 
stomach  the  base  of  which  contained  eroded  blood-vessels.  It 
was  a  case  of  embolism  the  origin  of  which  lay  in  a  septic 
affection  of  the  genitals. 

Gastritis  phlegmonosa. — Puerperal  fever  is  also  said 
to  lead  sometimes  to  a  metastatic  inflammation  of  the  walls 


DISEASES  OF  THE  ORGANS  OF  DIGESTION     419 

of  the  stomach   (gastritis  phlegmonosa)   which  may  result  in 
abscess  (Dietrich).1 

Dyspeptic  phenomena. —  The  abnormal  desires  of 
pregnant  women  which  manifest  themselves  by  a  longing  for 
sour,  spicy  articles  of  food,  by  a  ravenous  appetite  for  chalk 
and  similar  things,  are  too  well-known  to  require  more  than 
passing  notice;  nor  is  it  necessary  to  dwell  at  any  great  length 
on  the  simple  dyspeptic  disturbances,  want  of  appetite  amount- 
ing to  a  disgust  at  the  sight  of  food,  eructations,  heart-burning, 
etc.2  In  so  far  as  they  are  not  caused  by  direct  local  injuries, 
we  might  classify  these  disorders  among  the  reflex  neuroses. 
Here  also  the  above-mentioned  reflex  tracts  are  accused  by 
several  authors.  Tuszkai  sees  the  abdominal  centres  for  the 
internal  organs  in  the  solar  ganglion  or  the  inferior  hypogastric 
plexus  respectively,  which  goes  to  the  uterus  on  the  one  part, 
and  on  the  other  to  the  anterior  and  posterior  gastric  branches 
of  the  vagus. 

It  is  certain  however  that  pregnancy  conduces  also  by  purely 
mechanical  agencies  to  disturbances  in  the  gastric  functions. 
Through  the  relaxation  of  the  ligaments  by  which  the  abdominal 
organs,  principally  liver,  kidneys  and  stomach,  are  attached 
there  occurs  in  all  those  cases  in  which  a  return  to  normal 
conditions  does  not  take  place  after  parturition  mainly  in  con- 
sequence of  insufficient  hygiene  in  child-bed,  or  where  atrophy 
and  flabbiness  of  the  abdominal  muscles  have  resulted  from 
repeated  pregnancies — there  occurs  in  these  cases  a  prolapse  of 
the  organs,  and  conditions  develop  which  are  known  by  the 
name  of  Splanchnoptosis,  and  which  we  designate  accord- 
ing to  the  organ  chiefly  affected,  as  gastroptosis,  hepatoptosis, 
enteroptosis,  splenoptosis,  or  nephroptosis.  The  clinical  picture 
arising  in  consequence,  supplies  a  mixture  of  functional  (nerv- 
ous) and  organic  disorders  which  is  difficult  to  disentangle,  and 


1C.  A.  Ewald.  Klinik  der  Magenkrankh.  3d  edit.  p.  417. 

2In  Stinger's  and  v.  Herff's  "Encyclopadie  der  Geburtshilfe,"  Leipzig,  1900, 
there  is  a  pertinent  computation  in  percentages  of  the  individual  articles  of 
food;  thus,  for  instance,  the  longing  for  sour  things  has  been  observed  in 
34.5  per  cent,  of  the  cases,  for  sweet  things  in  5.4  per  cent,  for  food  and  fruit 
in  1.8  per  cent.  This  tabulation  cannot,  however,  be  said  to  possess  much  prac- 
tical value. 


420  HEALTH,  DISEASE,  MARRIAGE 

which  we  cannot  attempt  to  discuss  here  in  detail,  as  it  would 
take  us  too  far.  It  is  well  known  that  we  can  obtain  the  best 
results  in  the  treatment  of  these  affections  by  the  mechanical 
appliance  of  suitable  bandages  or  by  operativ.e  fixation  of  the 
displaced  organ,  if  we  at  the  same  time  institute  a  generally 
strengthening  hygienic-dietetic  regimen  directed  against  the 
neuroses.1 

Meanwhile  we  have  somewhat  deviated  by  these  remarks 
from  our  immediate  subject,  namely  the  injuries  which  happen 
to  women  during  pregnancy  and  parturition. 

Gastric  and  intestinal  catarrh. — Returning  to  it 
again,  we  come  across  pregnancies  which  are  seriously  endan- 
gered by  the  presence  of  acute  gastro-intestinal  catarrhs,  and 
which  lead  to  severe  vomiting  and  diarrhoea.  The  loss  of 
strength  is  so  great,  that  a  suspicion  of  tuberculosis  of  the 
intestines  or  of  some  other  malignant  disease  arises,  especially 
if  convulsions  and  eclamptic  attacks  accompany  the  condition. 
White  reports  the  case  of  a  primipara  who  had  overloaded  her 
stomach  and  acquired  a  violent  indigestion  shortly  before  the 
beginning  of  the  labour-pains.  At  the  end  of  the  expulsion- 
stage  the  pulse-rate  fell  from  80  to  48  beats.  Headache  and 
soon  afterwards  convulsions  made  their  appearance.  After 
severe  vomiting,  she  was  well  again. 

Hither  belong  also  those  acute  inflammatory  and  partly  diph- 
theritic processes  of  the  intestinal  mucous  membrane,  which  are 
communicated  in  puerperal  infections  from  the  genitals  to  the 
lower  portion  of  the  bowels. 

Chronic  catarrhs  of  the  small  and  large  intestine  are  capable 
of  determining  prematurely  by  miscarriage  a  developing  preg- 
nancy. That  simultaneously  existing  malignant  new  growths 
can  influence  pregnancy  most  unfavourably,  and  namely  in  part 
through  the  injury  to  the  general  metabolism  and  in  part  by 
mechanical  action  is  self-evident.  This  applies  particularly  to 
cancer  of  the  rectum  which  may  by  its  extent  and  by  encroaching 
upon  neighbouring  parts  become  a  severe  obstacle  in  labour. 

Laceration  of  the  intestines. — Spontaneous  lacera- 
tion of  the  bowels  and  of  the  omentum,  strange  as  it  may  seem, 


1L.  Landau,  Wanie richer  und  Hangebauch,  Berlin,  1885. 


DISEASES  OF  THE  ORGANS  OF  DIGESTION    421 

has  been  several  times  observed  during  parturition.  (Stump f, 
Schneider,  Schdfer,  L.  Meissner.)1  In  one  case  there  had  pre- 
viously been  peritonitis  present  which  had  given  rise  to  adhesions 
between  the  bowels  and  the  anterior  abdominal  wall.  The  small 
intestine  was  torn  in  two  places.  In  the  other  cases  the  cause  of 
the  lacerations  in  the  coecum  and  colon  remained  unexplained. 

It  is  not  however  pregnancy  and  the  labour  act  only  which 
favour  the  production  of  gastric  and  intestinal  disorders.  The 
lying-in  period  as  well  can  do  so.  The  sudden  dislocation  of 
the  stomach  which  was  before  parturition  compressed  and 
pushed  upwards,  the  rest  in  bed,  the  paresis  of  the  intestinal 
tract  during  the  puerperium  predispose  to  disorders  of  digestion 
and  to  gastric  and  intestinal  catarrhs.  They  are  more  apt  to 
cause  pyrexia  than  is  coprostasis  and  are  capable  of  producing 
extreme  prostration. 

Constipation. — Here  we  have  to  mention  in  the  first 
instance  persistent  constipation  which  frequently  attains  most 
extreme  degrees  so  that  the  poor  women  have  already  tried  in 
vain  the  whole  pharmacopoeia  of  internal  and  external  remedies 
and  all  the  appliances  of  the  "physico-dietetic"  method  of 
treatment  by  the  time  they  come  to  us  with  their  complaints ! 

As  a  consequence  of  chronic  constipation  during  pregnancy 
and  child-bed  Edlefsen2  has  described  an  inflammation  which 
extends  round  the  sigmoid  flexure,  in  other  words,  a  perisigmoi- 
ditis  or  pericolitis. 

For  these  constipations  the  pressure  of  the  growing  uterus 
upon  the  bowel  has  been  made  responsible,  but  surely  without 
reason,  or,  at  any  rate,  with  very  little  and  only  temporary 
justification.  Because  the  constipation  begins  in  many  women 
at  the  commencement  of  the  pregnancy  when  the  above-men- 
tioned cause  is  as  yet  unavailable,  and  it  persists  or  appears 
even  afresh  after  parturition  when  there  is  equally  no  longer 
any  question  of  pressure.  The  probability  is  that  the  cause 
lies  in  an  atony  of  the  intestinal  muscular  walls  which  is  partly 
nervous  in  origin  and  partly  occasioned  by  the  complex  of  the 
above-named  injurious  influences. 


Compare  with  C.  A.  Ewald,  Klinik  d.  Magenkrank.  3d  edit.  p.  177. 
*Edleffsen,  Berl.  klin.  Wochens.  1903.  No.  48. 


422  HEALTH,  DISEASE,  MARRIAGE 

Herniae. —  Among  the  disorders  of  the  intestinal  tract 
which  are  either  created  or  aggravated  by  pregnancy  are  included 
hernias.  I  extract  the  following  statements  from  a  communica- 
tion by  Manley  :l  Inguinal  and  femoral  hernias  are  never  caused 
by  pregnancy,  but  occasionally  aggravated  by  it.  The  pregnant 
uterus  is  never  the  cause  of  an  incarceration.  If  the  latter 
however  occurs  for  other  reasons — and  pregnancy  by  increasing 
the  intra-abdominal  pressure  favours  this — the  necessary  opera- 
tion is  always  followed  by  miscarriage  or  premature  labour. 
Umbilical  hernia  may  become  greatly  enlarged  by  repeated 
pregnancies  or  even  be  caused  directly  by  them.  The  latter  is 
certainly  the  case  as  regards  the  abdominal  herniae  the  pro- 
duction of  which  is  very  much  facilitated  by  the  atrophy  of 
the  adipose  layer  during  pregnancy  and  the  intensive  stretching 
or  rupture  of  the  muscular  wall  during  the  labour  pains. 
Manley  reports  the  cure  of  a  case  of  this  kind  in  which  the 
contents  of  the  hernial  sac  consisted  of  omentum,  and  which 
it  was  possible  to  remove.  Kutiak  (quoted  by  P.  Muller)2  saw 
in  a  left  inguinal  hernia  in  the  third  month  of  the  third  preg- 
nancy an  inflammation  of  the  hernial  sac  which  ended  with  the 
formation  of  an  anus  praeternaturalis.  The  faecal  fistula  closed 
in  the  8th  month  of  the  pregnancy  and  a  normal  parturition 
took  place  subsequently. 

Should  it  unfortunately  happen  that  the  uterus  is  situated 
in  such  an  old  hernial  sac,  miscarriage  or  a  severe  obstruction  to 
labour  will  most  likely  result  necessitating  a  fresh  operation. 
Eisenhardt  describes  an  incarceration  of  the  right  horn  of  a 
3  months'  pregnant  uterus  in  an  inguinal  hernia,  Skrivaz  an 
extra-uterine  pregnancy  also  in  an  inguinal  hernia.  We  must 
not  forget  to  mention  that  according  to  older  authors,  f.  i. 
P.  Mtiller,  as  opposed  entirely  to  Manley,  pregnancy  and  espe- 
cially repeated  pregnancies  supply  a  predisposing  element  in  the 
production  of  herniae.  At  any  rate  strangulation  occurs  very 
seldom  during  parturition  and  child-bed,  possibly  for  the  reason 


lTh.  Manley.  Hernia  in  pregnancy,  and  pregnancy  in  hernia.  Medical 
News  1901,  Jan.  27. 

2Die  Krank.  des  weibl.  Korpers  in  ihren  Wechselbez.  zu  den  Gesch- 
lechtsfunct.  Stuttgart  1888,  p.  96.  sq. 


DISEASES  OF  THE  ORGANS  OF  DIGESTION    423 

that  the  growing  uterus  forces  the  intestines  into  the  posterior 
and  upper  portions  of  the  abdominal  cavity  and  the  organ 
itself  is  placed,  so  to  speak,  against  the  door  of  the  hernia. 

Appendicitis. — An  important  part  with  respect  to  preg- 
nancy and  its  consequences  is  played  by  the  appendix  vermi- 
formis. 

That  pregnancy  predisposes  in  any  special  way  to  diseases 
of  the  appendix  is  not  known,  but  a  previously  existing  appendi- 
citis often  becomes  greatly  aggravated  during  pregnancy,  so 
that  most  serious  accidents  may  happen  and  a  comparatively 
light  mortality  may  result  in  consequence.  As  far  as  I  can 
see  Boye1  is  the  only  one  who  is  of  the  opinion  that  pregnancy 
has  no  particularly  injurious  influence  on  the  course  of 
appendicitis. 

Fellner  could  find  among  his  3800  births  only  one  case  which 
showed  a  previous  history  of  appendicitis  and  which  did  not 
exhibit  any  manifestations  during  pregnancy,  while  the  other 
3  cases  which  have  been  altogether  observed,  suffered  severe 
relapses.  We  may  mention  here  that  the  question  of  relation- 
ship between  appendicitis  and  the  diseases  of  the  female  sexual 
organs  has  produced  an  extensive  literature  a  collection  of  which 
will  be  found  in  the  gynaecological  annual  reports  of  Fellner, 
and  others.  From  the  same  we  gather  that  the  intense  conges- 
tion in  the  pelvic  organs  during  pregnancy  appears  to  favour 
in  the  majority  of  cases  of  existing  catarrhal  appendicitis  the 
formation  of  para-  or  peri-typhlitic  processes. 

Possibly  constipation  has  also  an  influence  in  that  direction. 
But  it  is  not  in  such  cases  always  easy  to  make  a  sharp  differential 
diagnosis  between  diseases  of  the  adnexa,  and  those  of  the  bowel, 
and  many  a  case  of  appendicitis  may  have  been  confused  with 
the  above-mentioned  diseases.  Should  a  perforation  of  the 
appendix  occur,  it  is  possible,  as  Fellner  says,  for  the  high  fever 
or  the  abnormally  low  temperature,  and  for  the  general  intoxi- 
cation or  the  collapse  to  produce  labour-pains  or  to  cause  the 
death  of  the  foetus.  According  to  Boye,  miscarriage  or  prema- 
ture labour  results  comparatively  often  even  without  such  a 


1Boye,  Uber  Appendicitis  in  Schw.  Geb.  u.  Wochenbett.  Mitteilungen  aus 
der  gynsecol.  Klinik  des  Prof.  Engstrdm.  Berlin,  Karger,  1903. 


424  HEALTH,  DISEASE,  MARRIAGE 

severe  complication.  There  is  also  a  possibility  that  pus-bacteria 
may  pass  through  the  Fallopian  tubes  to  the  placenta  and  the 
child,  and  this  is  how  it  is  that  in  many  embryos  septic  processes 
have  been  found. 

It  is  clear  that  the  labour-act  as  such  must  be  capable  of 
causing  on  account  of  the  spasmodic  contractions  during  the 
pains  the  perforation  of  encapsuled  exudations. 

As  a  matter  of  fact,  however,  the  perforation  takes  place 
generally  in  the  lying-in  period,  after  an  interval  of  some  days 
during  which  the  symptoms  have  somewhat  abated.  Konig1 
tries  to  explain  the  circumstance  that  the  perforation  happens 
later  and  not  during  the  parturition  stage,  by  supposing  that 
the  shrinking  uterus  pulls  so  as  to  speak  at  the  walls  of  a 
perityphlitic  abscess  and  damages  it  so  much  that  a  spontaneous 
rupture  occurs.  On  the  other  hand  Fellner  ascribes  to  the  uterus 
prior  to  parturition  a  direct  protective  capacity  inasmuch  as 
it  forms  a  reinforcement  of  the  neighbouring  abscess-wall.  In 
fact  purulent  perforation  of  the  uterine  wall  has  occasionally 
been  noticed,  as  f.  i.  in  a  case  mentioned  by  Konig. 

As  to  operative  interference  opinion  is  divided.  Frankel2 
recommends  in  the  case  of  a  simple  appendicitis  an  expectant 
attitude  whereas  in  recurring  cases  the  operation  is  indicated, 
especially  in  the  early  months  of  the  pregnancy.  Other  authors 
are  in  favour  of  a  more  active  procedure.  My  opinion  is  that 
the  same  principles  should  be  followed  in  these  cases,  inde- 
pendently of  the  pregnancy,  which  I  have  formulated  with 
regard  to  the  operative  treatment  of  appendicitis  in  my  "Klinik 
der  Darmkrankheiten."3  They  are  as  follows.  Operation  is 
indicated : 

1.  As  soon  as  a  perforation  with  general  peritonitis  has 
occurred,  or  is  manifestly  to  be  apprehended. 

2.  If  in  the  course  of  the  disease  an  accumulation  of  pus 
has  formed  under  symptoms  of  a  florid  and  progressive  nature. 


1R.  Konig,  Appendicitis  u.  Geburtshilfe.    Hegar's  Beitrage,  Vol.  II,  1900. 
*E.  Frankel,  Die  Append,  u.  ihre  Bez.  z.  Geburtsh.  u.  Gynaekol.  Volkmann, 
Sammlung  klin.    Vortr.  1901,  No.  323. 

*C.  A.  Ewald,  Die  Krankh.  d.  Darmes  u.  Bauchfelles.  Berlin  1902,  p.  258. 


425 

3.  In  recurrent  appendicitis,  which  has  become  a  source  of 
permanent  and  serious  danger  to  the  patient  on  account  of  the 
frequency  and  growing  severity  of  the  attacks. 

On  the  other  hand,  the  fourth  indication  laid  down  in  the 
above-quoted  work,  namely  the  presence  of  chronic  appendicular 
colic  and  of  appendicitis  larvata,  is  hardly  likely  to  arise  in 
connection  with  pregnancy  and  child-bed. 

Fellner  thinks  that  in  a  severe  attack  of  appendicitis  occur- 
ring towards  the  end  of  gestation  an  operation  is  indicated, 
since  there  is  a  certainty  that  otherwise  a  serious  relapse  will 
take  place,  during  parturition  or  during  the  puerperium  which 
will  necessitate  an  operation  under  far  less  unfavourable  cir- 
cumstances. Boye  quotes  31  operated  cases  with  14  fatal 
results.  Miscarriage  ensued  in  18  days  after  the  operation, 
generally  where  the  symptoms  were  very  severe.  The  operative 
interference  is  therefore  not  to  be  undertaken  lightly,  as  the 
prospects  are  in  consequence  of  the  concurrent  pregnancy  more 
unfavourable  than  under  other  circumstances. 

Opinion  is  also  not  undivided  on  the  question  of  the  induction 
of  premature  labour.  Konig  considers  the  latter  not  only 
unnecessary  but  also  dangerous.  For  if  labour  occurs  in  con- 
nection with  the  operation  for  appendicitis,  this  event  is  in 
many  cases  disastrous  for  the  woman.  This  is  the  reason  why 
Marx1  and  McArthur  recommend  the  evacuation  of  the  uterus 
immediately  before  or  after  the  operation,  but  Fellner  does 
not  think  he  can  advise  the  removal  of  the  foetus  in  the  second 
half  of  the  pregnancy  where  there  is  pus  present,  because  the 
prognosis  of  the  appendicitis  is  thereby  also  rendered  highly 
unfavourable. 

In  conclusion  it  is  scarcely  necessary  to  mention  that  all 
other  possible  acute  diseases  of  the  intestine  may  supervene  in 
the  course  of  pregnancy.  The  effect  of  the  latter  upon  these 
diseases  is  a  very  variable  one.  Frequently  it  contributes  to  an 
aggravation  of  their  course  and  oftentimes  again  it  seems  to 
exercise  no  particular  influence.  I  have  repeatedly  seen  mis- 
carriages occur  in  the  course  of  enteric  fever,  while  the  fever 


1Marx,  Appendicitis  complicating  pregnancy.  American  Journal  of  Obstet. 
1889,  No.  38. 


426  HEALTH,  DISEASE,  MARRIAGE 

itself  continued  its  progress  without  any  apparent  interruption. 
In  fatal  cases  it  is  of  course  not  possible  to  say  whether  death 
would  not  have  occurred  had  there  been  no  concurrent  preg- 
nancy. 

Changes  in  the  adnexa  and  in  the  peritone- 
um.—  A  very  important  and  long  chapter  is  formed  by  the 
changes  which  develop  in  the  adnexa  of  the  uterus  and  in  the 
peritoneum  in  connection  with  labour,  and  especially  during 
and  after  the  lying-in  period. 

As  a  continuation  of  the  above-described  inflammatory  and 
purulent  processes  which  affect  the  appendix  and  the  coecum, 
I  may  mention,  to  begin  with,  that  W '.  A.  Freund  has  described 
under  the  name  of  parametritis  chronica  atrophicans,  retracting 
inflammatory  processes  which  may  cause  in  addition  to  other 
adhesions  with  neighbouring  parts  and  their  consequent  dis- 
placement, a  dragging  downwards  of  the  coecum  and  appendix, 
a  shortening  of  the  mesentery  of  the  latter,  and  therefore 
permanent  disturbances.  It  is  not  always  easy  under  such  cir- 
cumstances to  find  out  the  real  state  of  things,  and  a  most 
careful  and  discriminating  examination  is  necessary  in  order 
to  establish  the  part  played  by  the  appendix  in  these  often 
vague  complaints  of  the  patients.  Such  cases  belong  to  the 
group  of  diseases  which  I  described  some  time  ago  as 
appendicitis  larvata.  It  is  clear  that,  apart  from  the  deformi- 
ties which  they  produce  in  the  uterus  itself  if  they  extend  lower 
down,  or  respectively  backwards,  upwards,  to  the  right  or  to  the 
left  and  if  they  give  rise  to  adhesions,  such  inflammatory  con- 
ditions and  infiltrations  are  capable  of  causing  not  only  perma- 
nent disturbances  in  the  functions  of  the  bowel,  but  also  acute 
attacks  resembling  obstruction  or  even  genuine  intestinal  obstruc- 
tion. 

Ileus. — Post-mortem  we  find  in  such  cases  the  intestines 
displaced  and  twisted  in  an  extraordinary  manner,  the  omentum 
rolled-up  and  almost  rope-like  in  appearance.  Quite  a  number 
of  appropriate  cases  are  recorded  in  literature  from  which  we 
find  that  the  whole  intestine  from  the  duodenum  down  to  the 
sigmoid  flexure  may  be  thus  affected.  Nothing  remains  then  to 
be  done  but  to  perform  laparotomy  and  to  liberate  the  strangu- 


DISEASES  OF  THE  ORGANS  OF  DIGESTION    427 

lated  portion  of  bowel  from  its  surroundings,  or  to  separate 
it  from  its  adhesions  with  neighbouring  parts.  It  is  not  neces- 
sary that  these  conditions  should  take  place  in  immediate  con- 
nection with  the  lying-in  period,  on  the  contrary  they  make 
their  appearance  as  a  rule  some  time  later,  perhaps  only  during 
a  subsequent  pregnancy  or  even  afterwards.  Thus  Hildebrandt 
reports  a  case  of  intestinal  obstruction  in  the  7th  month  which 
necessitated  the  induction  of  premature  labour.  Death  ensued 
on  the  yth  day  after  parturition.  It  was  found  that  there  was 
a  thick  band  going  from  the  uterus  to  the  omentum  which  had 
strangulated  a  coil  of  intestine. 

There  is  also  a  remarkable  case  reported  by  A.  Freund  in 
which  the  ileus  had  arisen  through  a  snapping-off  of  the  trans- 
verse colon  which  had  become  adherent  to  the  fundus  uteri.  A 
sarcoma  with  hydrometra  had  formed  in  the  uterus  which  had 
required  an  operation.  After  the  latter  the  uterus  had  sunk 
and  thus  broken  off  the  colon  adherent  to  It.  Here  also  a 
former  pregnancy  had  been  the  original  cause. 

Peritonitis  and  its  consequences. — Such  cases 
are  numerous  if  we  include  among  them  those  in  which  there 
had  been  puerperal  sepsis  and  diffuse  peritonitis  proceeding 
from  it.  "One  sees  here  the  most  variable  contortions  of  the 
affected  organs,  so  that  there  arise  in  succession  manifold  devia- 
tions of  intestine  and  uterus  with  fixation  of  the  adnexa,  which 
the  operating  surgeon  to  his  sorrow  knows  but  too  well,  and 
which  produce  the  most  multifarious  functional  disturbances. 
I  will  mention  from  among  them  only  3  sharply  characteristic 
types :  (  i )  The  agglutination  of  the  fundus  of  Douglas's  pouch 
by  pseudo-membranes  with  patency  of  the  atrium.  (2)  The 
extension  of  the  attaching  pseudo-membranes  up  into  the  atrium 
so  that  the  uterus  and  rectum  are  closely  matted  together,  gen- 
erally more  so  on  one  side  than  on  the  other.  (3)  The  forma- 
tion of  fan-like  bands  which  stretch  from  the  fundus  of  the 
uterus  to  the  higher  parts  of  the  rectum  and  to  the  iliac  flexure. 
Under  certain  circumstances  it  is  possible  in  the  case  of  tense 
union  between  the  uterus  and  the  iliac  flexure  for  elevation  of 
the  uterus  to  cause  complete  separation  of  the  rectum.  This 
condition  explains  the  persistence  of  obstinate  and  even  danger- 


428  HEALTH,  DISEASE,  MARRIAGE 

ous  obstructions  during  pregnancy  or  during  the  development 
of  tumours  with  elevation  of  the  uterus."1 

It  is  sufficient  for  our  purpose  to  have  pointed  out  these 
conditions.  In  chronic  cases  or  after  the  cessation  of  the  acute 
inflammatory  process  there  may  supervene  sub-paralytic  con- 
ditions, meteorism,  congestions  in  the  lower  abdomen,  haemor- 
rhoids, varicose  veins,  and,  as  we  hardly  need  mention,  more 
or  less  obstinate  constipation,  which  constitutes  a  source  of 
constant  complaint. 

These  troubles  may,  as  we  can  easily  imagine,  be  temporarily 
relieved  by  a  fresh  pregnancy,  as  the  conditions  in  the  abdominal 
cavity  become  considerably  altered  in  consequence,  approaching 
more  nearly  those  which  existed  previous  to  the  commencement 
of  the  injuries  in  question.  On  the  other  hand,  the  influence  of 
pregnancy  and  parturition  upon  an  intercurrent  peritonitis  is 
decidedly  unfavourable.  At  least  half  the  number  of  patients 
die. 

Haemorrhoids.  Prolapse  of  rectum. — Among 
this  selection  of  disagreeable  incidents  haemorrhoids  deserve 
special  mention.  They  constitute  along  with  chronic  consti- 
pation quite  a  prominent  portion  of  the  complaints  occasioned 
by  pregnancy  and  child-birth.  They  partly  begin  in  the  course 
of  these  processes  and  partly  they  undergo  an  aggravation 
while  these  processes  exist.  Thus  haemorrhoids  situated  high 
up  may  be  expelled  from  the  anus  by  the  labour  act,  and  may 
subsequently  during  the  lying-in  period  produce  with  the  retrac- 
tion of  the  anus  a  strangulation  with  all  its  consequences.  Rup- 
tures and  serious  haemorrhages,  inflammatory  swelling  of  the 
nodes  accompanied  by  severe  pain,  and  occasionally  gangrene 
may  supervene.  In  other  cases  the  nodes  appear  during  preg- 
nancy or  child-bed  in  consequence  of  the  congestion  in  the 
abdominal  circulation  and  of  the  constipation.  Hither  belong 
also  the  prolapus  recti  and — in  rare  cases — the  rectocele 
vaginalis,  caused  by  the  relaxation  of  the  vaginal  wall,  condi- 
tions which  may  on  account  of  the  faecal  accumulation  in 
the  pouch  prove  occasionally  an  obstacle  to  labour. 


*W.  A.  Freund,  Zur  Anatomic,  Physiologic  u.  Pathol.  d.  Douglastasche. 
Hegar's  Beitr.  Vol.  II,  No.  3,  p.  337. 


DISEASES  OF  THE  ORGANS  OF  DIGESTION    429 

2.  Diseases  of  the  pancreas,  liver  and  spleen. 

Pancreas  and  pregnancy. — The  relations  between 
the  pancreas  and  pregnancy  are  of  an  extremely  uncertain 
nature. 

With  regard  to  the  often-quoted  case  of  Haidlen1  in  sup- 
port of  an  acute  primary  pancreatitis — death  of  a  parturient 
woman  in  the  6th  week  of  the  puerperium,  no  pronounced  peri- 
tonitis, enlarged  pancreas  which  was  transformed  into  a  brown- 
red  mass  suffused  with  blood — I  am  inclined  to  more  than 
doubt  its  connection  with  the  pregnancy  or  the  puerperium 
and  to  regard  an  accidental  complication  as  by  no  means 
impossible. 

As  to  the  secondary  acute  purulent  inflammations  of  the 
pancreas,  Oser2  says  in  his  well-known  monograph  that  it  is 
possible  for  metastatic  abscesses  to  form  in  the  pancreas  in  the 
course  of  pyaemia  and  puerperal  fever,  but  that  such  cases  are 
very  rare.  In  the  post-mortem  reports  of  the  General  Hospital 
of  Vienna  for  the  years  1888-1898  there  is  not  a  single  perti- 
nent case. 

Though  we  can  say  this  much  with  respect  to  the  acute 
diseases  we  are  entirely  in  the  dark  in  so  far  as  the  relations 
between  the  chronic  inflammatory  processes  or  new  growths  in 
the  pancreas  and  the  married  state  or  pregnancy,  etc.,  are 
concerned.  That  a  tumour  or  cyst  of  the  pancreas  is  occasion- 
ally met  with  in  a  pregnant  woman  does  not  prove  any  internal 
connection  between  the  two  processes. 

Diseases  of  the  liver. — The  diseases  of  the  liver 
have  always  attracted  the  special  attention  of  medical  men, 
because  they  lead  to  the  most  apparent  and  sometimes  gravest 
changes  in  those  organs  which  are  not  immediately  connected 
with  the  generative  organs  proper. 

Jaundice. — Not  infrequently  we  observe  in  the  first  month 
of  pregnancy  slight  jaundice  which  we  cannot  explain  differ- 
ently than  that  it  is  caused  by  a  gastro-duodenal  catarrh,  such 


1Haidlen,  Acute  Pankreatitis  im  Wochenbett.    Centralblatt    f.    Gynakol. 
1884,  No.  39. 

*L.  Oser,  Die  Erkrank.  der  Pancreas.    Vienna  1878,  p.  161. 


430  HEALTH,  DISEASE,  MARRIAGE 

as  we  often  come  across.  Whether  this  form  of  jaundice  has 
any  causal  connection  with  the  pregnancy  must  be  left  undecided. 
Should  it  occur  during  the  lying-in  period  or  later,  it  is 
possible  for  the  bile-acids  to  pass  into  the  milk,  but  accord- 
ing to  Frank1  not  in  such  quantities  as  to  do  any  harm  to  the 
child. 

In  very  rare  cases,  however,  jaundice  seems  to  develop  from 
an  accidental  and  occasional  occurrence  into  a  complication 
recurring  regularly  with  each  subsequent  pregnancy  of  multi- 
parous  women.  Brauer*  and  Meinhold3  have  described  as 
haemoglobinuria  of  pregnancy  a  clinical  picture  in  which  the 
two  respective  women  exhibited  at  each  succeeding  pregnancy 
during  the  last  months,  lassitude,  nervous  irritability,  pruritus, 
and  slight  jaundice  as  symptoms  of  an  haemoglobinuria. 

Brauer4  has  observed  a  further  case  of  jaundice  recurring 
with  each  pregnancy,  but  without  haemoglobinuria.  There  are 
a  few  other  cases  (3)  in  literature  of  the  same  nature.  This 
phenomenon  is  said  to  occur  frequently  in  Italy  in  the  case  of 
pregnant  women  suffering  from  malaria  (Bossi).  It  is  prob- 
able that  the  cause  lies  in  an  haematogenous  jaundice  produced 
by  blood-poisons.  (See  below.)  All  these  cases  ran  a  benign 
and  mild  course. 

Acute  yellow  atrophy  of  the  liver. — Things  are 
however  totally  different  as  regards  the  severe,  acutely  super- 
vening and  mostly  fatal  cases  of  jaundice  which  appear  in  the 
middle  or  the  second  half  of  pregnancy  (icterus  gravidarum 
gravis;  puerperal  acute  yellow  atrophy  of  liver).  The  disease 
begins  generally  with  a  rigor,  the  liver  and  spleen  become 
swollen,  there  is  severe  jaundice,  pains  in  the  region  of  the 
liver  which  take  a  colicky  character,  haematemesis  and  melsena, 
eventually  meteoritic  distension  of  the  abdomen.  In  the  further 


1F.  Frank,  Untersuchungen  iiber  die  Frauenmilch  bei  Icterus.  Diss.  Gies- 
sen. 

*L.  Brauer,  Ueber  Graviditatshamoglobinurie.  Miinchener  med.  Wo- 
chenschr.  1902.  Nr.  20. 

*Meinhold,  Ein  weiterer  Fall  von  Schwangerschaftshamoglobinurie.  Ibid. 
1903.  Nr.  4. 

*L.  Brauer,  Ueber  Graviditatsicterus.  Centralb.  f.  Gynakologie.  1903. 
Nr.  26. 


DISEASES  OF  THE  ORGANS  OF  DIGESTION     431 

course  of  the  malady  the  liver  grows  very  rapidly  in  volume, 
it  becomes  flabby  and  falls  backwards  so  that  it  is  covered  by 
intestine  and  the  liver  dulness  disappears. 

The  urine  contains  besides  bile-pigments,  also  urobilin  and 
bile-acids,  and  likewise  albumen.  Similarly  leucine  and  tyrosine 
have  been  found  present,  but  they  are  not  by  any  means  essential 
attributes.  The  disease  ends  fatally  in  the  great  majority  of 
cases.  Red  and  yellow  atrophic  regions  alternate  in  the  dimin- 
ished liver,  which  presents  a  flabby,  leathery  constitution.  In 
the  yellow  parts  there  are  remains  of  liver-tissue,  the  cells  of 
which  are  in  a  high  degree  of  fatty  degeneration,  whilst  the  red 
parts  consist  almost  entirely  of  connective  tissue  in  which 
appear  a  typical  interlobular  bile-duct  excrescences.  The  other 
parenchymatous  organs,  especially  the  kidneys  show  equally 
a  more  or  less  advanced  fatty  degeneration.  Haemorrhages 
into  the  serous  membranes  are  not  infrequent,  as  are  not  also 
bloody  contents  in  the  stomach  and  intestines. 

The  whole  clinical  picture  which  I  have  reproduced  here 
in  brief  in  order  to  show  its  septic  character  is  undoubtedly 
based  upon  a  severe  infection,  the  starting-point  of  which  is 
either  the  gastro-intestinal  canal  or  the  genital  tract,  the  infec- 
tion proceeding  either  directly  from  the  latter  or  because  preg- 
nancy creates  a  special  predisposition  to  the  disease.  That  we 
have  here  nothing  more  than  an  aggravated  catarrhal  jaundice 
as  Schroder  and  Lomer  maintained,  and  as  Fellner  also  seems 
inclined  to  admit,  is  altogether  out  of  the  question,  although 
solitary  cases  do  occasionally  recover  in  which  a  doubt  may 
arise  as  to  whether  they  were  severe  forms  of  catarrhal  jaundice, 
etc.  or  light  forms  of  acute  yellow  atrophy.  Whether  we  take 
the  cause  to  be  peculiar  metabolic  processes  during  pregnancy 
and  the  formation  of  so-called  placental  toxins  ( Syncytolysin, 
Veil}  or  a  bacterial  infection,  is  in  view  of  the  absence  of  all 
evidence  on  the  point  quite  immaterial. 

The  typical  cases,  however,  bear  during  the  entire  course  of 
the  illness  such  unmistakable  marks  of  infectiousness  that  we 
cannot  be  much  in  doubt  though  we  are  as  yet  without  proof 
of  the  existence  of  a  specific  infectious  virus.  It  is  true  that 
Strobl  has  demonstrated  the  presence  of  the  bacterium  coli 


432  HEALTH,  DISEASE,  MARRIAGE 

commune,  and  Richard  Freund1  that  of  a  staphylococcus,  but 
considering  the  ubiquity  of  these  microbes,  this  is  not  of  much 
value.  On  the  other  hand,  it  must  not  be  overlooked  that  in 
consequence  of  pregnancy  conditions  are  undoubtedly  created 
which  occasion  changes  in  the  circulation  of  the  liver,  and  espe- 
cially a  slowness  in  the  secretion  of  bile,  swelling  of  the  mucous 
membranes  of  the  bile-ducts  and  of  the  papilla  duodenalis, 
changes  by  which  the  entrance  of  microbes  into  the  liver  is 
facilitated.  The  intoxication  of  the  blood  by  the  admission 
of  bile-acids  and  other  toxins  which  we  designate  as  cholaemia, 
favours  the  deleterious  course  of  the  disease.  Happily  acute 
yellow  atrophy  is  very  rare;  according  to  Spaeth  it  occurs  once 
in  16,000,  and  according  to  Douglas  once  in  28,000  cases! 

Acute  yellow  atrophy  of  the  liver  appears  occasionally  in 
an  epidemic  form  without  any  direct  connection  with  pregnancy, 
but  then  it  would  seem  as  if  pregnant  women  are  particularly 
liable  to  be  attacked.  Charpentier  saw  during  an  epidemic 
in  the  neighbourhood  of  Roubaix  1 1  pregnant  women  succumb 
to  icterus  gravis,  and  similar  numbers  are  reported  with  respect 
to  other  epidemics.  Whereas  some  writers  have  seen  a  more 
favourable  course  of  the  disease  after  the  supervention  of  prema- 
ture labour,  others  deny  such  an  influence  and  recommend  an 
expectant  attitude  since  parturition  does  not  affect  the  illness 
in  any  way. 

Abscess  of  liver,  fatty  liver,  cirrhosis  of  liver. 
— There  are  also  other  secondary  affections  of  the  liver  which 
may  be  traced  directly  to  a  puerperal  infection,  in  contrast  to  the 
disease  just  mentioned  in  which  the  affection  of  the  liver  occupies 
the  primary  place  of  the  clinical  picture.  Among  them  are 
abscesses  of  the  liver,  and  acute  fatty  degenerations  of  the  he- 
patic parenchyma  with  atrophy  of  the  latter.  Where  these 
conditions  become  healed  up,  it  is  possible  for  connective-tissue 


1R.  Freund,  Ueber  den  Ausgang  der  akuten  Leberatrophie  in  Cirrhose. 
Diss.  Freiburg  1897. 

Translator's  note :  In  the  British  Medical  Journal  of  May  2,  1896,  I 
mentioned  a  very  interesting  case  of  acute  yellow  atrophy  in  connection  with 
pregnancy,  the  most  striking  feature  of  which  was  that  the  disease  was  cured 
by  a  supervening  attack  of  erysipelas. 


433 

proliferation  to  form  which  gives  to  the  disease  the  appearance 
of  a  cirrhosis.  To  this  group  of  diseases  probably  belongs  also 
a  fatty  degeneration  of  the  liver,  kidneys  and  heart-muscle 
observed  by  C.  Hecker  and  Buhl  and  by  Klebs.1  In  the  cases 
described  the  illness  commenced  during  pregnancy  with  symp- 
toms of  an  affection  of  the  kidneys  or  of  the  heart,  became 
graver  at  parturition  and  ended  fatally  during  the  lying-in  period. 
Pyrexia  may  be  absent  altogether.  Death  may  occur  among 
signs  of  severe  collapse  or  cholaemia.  In  the  liver  were  found 
haemorrhagic  deposits  arranged  in  groups,  pronounced  fattiness 
of  the  liver-cells,  thrombi  in  the  portal-vein  branches  which 
consisted  of  blood-platelets  and  degenerated  or  unchanged  liver- 
cells.  The  causes  are  unknown,  in  any  case  there  was  no 
demonstrable  local  affection  of  the  genitals. 

We  have  also  yet  to  mention  haemorrhages  from  the  genital 
organs,  or  better  said  from  the  uterus,  and  from  the  haemor- 
rhoidal  veins,  which  may  take  place  during  pregnancy  co-exist- 
ing with  a  simultaneous  cirrhosis  of  the  liver.  They  are  char- 
acterised by  the  peculiar  quality  that  they  cannot  be  arrested 
by  the  ordinary  means,  and  that  they  resemble  more  the  oesoph- 
ageal  haemorrhages  which  are  known  to  us  as  complications 
of  cirrhosis  of  the  liver.  The  reason  is  that  the  veins  belonging 
to  the  uterus  and  vagina  terminate  in  the  middle  and  superior 
haemorrhoidal  veins,  which  in  their  turn  form  together  with  the 
colic  veins  the  inferior  mesenteric  vein,  which  again  terminates 
in  the  splenic  vein,  a  branch  of  the  portal  vein.  Every  conges- 
tion in  the  portal  system,  that  is,  every  obstacle  which  the  flow 
of  the  portal-vein  blood  meets  within  the  liver  reacts  on  these 
veins,  the  more  so  as  pregnancy  alone  causes  to  begin  with  con- 
gestive conditions  in  the  abdomen.  The  result  is  a  dilatation 
and  rupture  of  the  minute  and  delicate  blood-vessels,  and  the 
above-mentioned  haemorrhages. 

Gall  Stones. — Pregnancy  has  always  been  looked  upon 
as  a  predisposing  factor  in  the  origin  of  gall-stones.  Statistics 
show  that  in  a  considerable  number  of  cases  the  first  symptoms 


*Klebs,  Multiple  Leberzellenthrombose,  ein  Beitrag  zur  Entstehung 
schwerer  Krankheitszustande  in  der  Graviditat.  Ziegler's  Beitrage  Bd.  3 
Heft  i. 


434  HEALTH,  DISEASE,  MARRIAGE 

of  the  illness  appeared  during  or  immediately  after  child-bed. 
Thus  Cyr  found  among  51  cases  of  gall-stones  22  with  such 
a  history.  Naunyn,  Huchard  and  others  express  a  similar 
opinion.  Naunyn  says  that  of  115  cadavers  of  adult  women, 
containing  gall-stones,  only  10  had  not  gone  through  any  preg- 
nancies. It  is  evident  that  the  above-mentioned  influences  of 
pregnancy  on  the  circulation  in  the  liver  favour  the  formation 
of  gall-stones;  the  same  thing  applies  to  the  displacements  of 
the  liver  which  appear  as  consequences  of  parturition.  That 
the  calculi  become  mobile  during  pregnancy  and  during  the 
labour  act,  that  they  occasion  colics,  and  that  they  eventually 
escape,  is  nothing  remarkable.  The  direct  connection  cannot 
therefore  always  be  demonstrated  with  certainty. 

So  as  to  exhaust  completely  the  list  of  diseases  of  the  liver 
there  remains  only  to  be  mentioned  in  conclusion  that  cancer 
of  the  liver  generally  takes  during  pregnancy  a  particularly 
rapid  course,  that  it  leads  to  extreme  cachexia  of  the  women 
and  that  it  accelerates  the  fatal  issue. 

Spleen. —  The  relations  of  the  spleen  to  the  processes 
which  interest  us  here  do  not  really  belong  to  the  chapter  on 
"Diseases  of  the  organs  of  digestion  in  relation  to  marriage," 
but  it  is  not  unadvisable  to  enumerate  them  briefly  on  this 
occasion.  There  are  only  two  or  three  changed  conditions 
affecting  this  organ.  They  are:  the  enlargement  of  the  spleen 
which  is  one  of  the  symptoms  of  a  general  septic  infection,  and 
the  rupture  of  the  capsule  or  of  the  spleen  itself  with  consequent 
haemorrhage  into  the  abdominal  cavity,  which  has  been  several 
times  observed  in  connection  with  pregnancy  and  parturition. 
According  to  /.  Y.  Simpson  the  soft  consistence  of  the  spleen 
is  likely  to  predispose  to  rupture  of  the  capsule,  a  supposition 
with  which  we  cannot  agree,  because  the  capsule  is  firmer  and 
tenser  than  the  soft  pulp,  and  because  the  reported  cases  have 
shown  an  acute  rupture  and  not  a  previous  disease  of  the  spleen 
which  might  have  predisposed  to  a  friability  of  the  organ. 
Neither  was  the  cause  of  the  rupture  clear  in  the  frequently 
quoted  case  of  P.  Miiller — death  from  ruptured  aneurysm  of 
the  splenic  artery  3  hours  after  parturition. 

That  the  spleen,  like  the  kidneys,  etc.  may  become  loose  in 


DISEASES  OF  THE  ORGANS  OF  DIGESTION    435 

its  ligamentous  apparatus  and  acquire  an  abnormal  mobility 
which  permits  it  to  take  up  a  position  in  the  diaphragmatic 
excavation  more  or  less  distant  from  its  normal  situation,  in 
other  words  that  the  organ  may  become  a  so-called  "wandering 
spleen" — is  a  subject  belonging  to  the  above-considered  chapter 
dealing  with  the  prolapse  of  the  abdominal  organs,  and  only 
requires  here  passing  notice. 


Favourable  Influence  of  Marriage,  as  Regards  the  Wife. 

In  attempting  now  to  describe  the  advantages  accruing  to 
the  wife  from  the  married  state,  as  against  the  long  and  sad  list 
of  diseases  enumerated  in  the  first  part  of  this  chapter,  we  must 
admit  to  our  sorrow  that  there  is  very  little  to  say.  This  does 
not  of  course  mean  that  the  benefit  which  the  wife  derives  from 
marriage — with  reference  to  the  organs  of  digestion — is  corre- 
spondingly small  and  that  the  above  enumeration  of  the  ills 
and  woes  to  which  she  is  liable  constitutes  the  regular  state 
of  affairs;  nor  does  it  mean  that  marriage  is  an  institution 
against  which  we  must  warn  in  any  case. 

The  fact  is  that  the  above-described  conditions  are  exceptions 
only — although  some  of  them  have  almost  become  the  rule — 
and  that  the  vast  majority  of  women  do  not  fare  so  badly! 
How  many  anaemic,  chlorotic,  and  nervous  young  girls  who 
were  before  their  marriage  subject  to  all  kinds  of  digestive 
troubles  develop  during  married  life  into  strong  and  healthy 
women  with  an  excellent  appetite  and  perfectly  normal  functions 
of  all  the  organs  concerned.  In  fact,  even  severe  constitutional 
diseases  may  disappear  or  not  come  to  development  where  there 
is  an  hereditary  predisposition  to  them,  provided  of  course 
that  the  digestive  organs  do  not  suffer  and  that  they  exercise 
their  functions  properly.  There  is  in  this  connection  in  W.  A. 
Freund's  "Gynaecologische  Klinik"1  a  most  interesting  and  per- 


*W.  A.  Freund,  Gynaek.  Klinik,  Strassburg  1885,  p.  353. 


436  HEALTH,  DISEASE,  MARRIAGE 

haps  not  sufficiently  known  example.  Considering  the  impor- 
tance of  the  subject  I  will  reproduce  the  same  in  the  author's 
own  words: 

"The  wife  of  a  medical  friend  is  descended  from  a  tuber- 
culously  predisposed  family.  Her  mother  had  died  when  between 
30  and  40  years  old  from  pulmonary  tuberculosis  and  likewise 
her  oldest  sister  after  a  short  sterile  married  life.  She  herself 
was  19  years  old  when  she  married,  delicate,  tall  in  stature, 
with  narrow  chest  and  troubled  with  a  severe  cough.  She  gave 
birth  at  intervals  of  about  2  years  to  5  children  each  of  which 
she  suckled  for  about  6-9  months.  I  have  seen  this  lady 
during  all  this  time  growing,  if  I  may  say  so,  stronger  and 
healthier;  she  developed  into  a  model  of  robustness,  and  is  at 
the  present  day  as  a  matron  50  years  of  age  one  of  the  most 
handsome  women  in  the  neighbourhood  where  she  lives.  After 
the  death  of  the  above-mentioned  eldest  sister  the  widower 
proposed  marriage  to  a  third  sister  living  under  the  roof  of 
my  friend,  her  brother-in-law.  The  girl  was  alarmingly  deli- 
cate, had  had  a  cough  for  many  years,  and  haemoptysis  several 
times.  The  apex  of  the  left  lung  showed  signs  of  consolidation. 

"My  friend  and  I  had  a  consultation  over  the  matter  and 
we  decided  to  inform  the  would-be  husband  of  the  real  state 
of  affairs  and  to  oppose  the  marriage  strenuously.  Fortunately 
for  him  and  for  the  girl  the  gallant  and  enamoured  officer 
pooh-poohed  our  warning,  and  we  experienced  in  the  young 
married  woman  the  same  pleasant  surprise  as  in  her  elder  sister. 
She  gave  birth  in  fairly  rapid  succession  to  3  children  whom  she 
suckled,  and  all  the  while  she  became  steadily  stronger  and 
more  vigorous  so  that  she  is  considered  to-day  one  of  the 
healthiest  women  of  her  acquaintance.  Both  sisters,  the  elder 
one  now  in  the  fifties  and  the  younger  one  in  the  forties  have 
survived  their  husbands  who  were  both  in  very  good  health. 
According  to  our  modern  terminology  both  have  so  far  altered 
the  state  of  their  organism  that  they  no  longer  offer  any  suitable 
soil  for  the  growth  of  the  tubercle-bacillus.  For  the  better 
understanding  of  these  experiences,  it  is  necessary  to  add  that 
the  first-mentioned  wife  of  my  medical  friend  lost  a  boy  one  year 
old  with  symptoms  of  meningitis  and  her  eldest  daughter  at 


437 

the  age  of  20  from  pulmonary  tuberculosis  about  4  months 
after  her  first  confinement." 

Such  experiences  would  not  be  possible  without  the  favour- 
able influence  which  married  life  can  exert  on  the  general  state 
of  nutrition,  that  is,  on  the  metabolic  processes  of  the  female 
organism.  We  do  not  refer  here  to  the  above-mentioned  more 
or  less  diseased  individuals,  but  to  those  delicate  and  fragile 
creatures  who  develop  during  the  married  state  into  robust, 
resistant  and  "embonpoint"  women.  There  are  plenty  of 
instances  though  they  naturally  find  no  place  in  gynaecological 
text-books. 


Influence  of  Diseases  of  the  Digestive  Apparatus  on  the 
Contraction  of  Marriages. 

The  question  is  to  be  discussed,  finally,  whether  one  of  the 
above-considered  diseases  of  the  digestive  organs  (including 
the  liver  and  spleen)  may  form  a  reason  for  prohibiting  a  con- 
templated marriage  or  for  advising  against  it.  Of  course  only 
a  portion  of  these  diseases  may  give  rise  to  such  considerations. 
Because  persons  with  pronounced  cancer  of  the  liver  or  of  the 
stomach,  persons  afflicted  with  cancer  or  manifest  tuberculosis 
of  the  intestines  or  who  are  strongly  suspected  of  being  thus 
afflicted,  persons  with  pernicious  anaemia,  severe  chronic  dysen- 
tery or  similar  affections  must  not  only  be  dissuaded  from  mar- 
rying, but  actually  and  directly  forbidden,  where  this  is  at 
all  possible. 

A  great  deal  certainly  depends  upon  circumstances,  and 
we  may  well  imagine  cases  where  such  marriages  can  take 
place  with  the  consent  of  both  parties,  always  provided  that 
neither  of  them  is  in  the  dark  as  to  the  true  state  of  things. 
Regard  for  the  offspring  must  in  such  cases  also  play  an  impor- 
tant part.  Where  there  is  a  possibility  of  children  being  born 
to  a  father  or  mother  suffering  from  an  hereditary  disease, 
marriage  is  a  priori  out  of  the  question,  at  least  theoretically, 


438  HEALTH,  DISEASE,  MARRIAGE 

but  in  most  such  diseased  conditions  there  is  to  begin  with  a 
physical  incapacity  which  precludes  the  possibility  of  conception. 
Generally  speaking  these  cases  cannot  be  decided  by  fixed  rules 
but  each  one  must  be  considered  on  its  merits  and  with  a  full 
appreciation  of  all  the  factors  concerned. 

It  is  different  as  regards  the  other  diseases  considered  above 
but  they  can  only  interest  us  in  this  connection  if  they  were 
acquired  previously  to  marriage. 

That  the  married  state  can  be  nothing  but  beneficial  to  the 
great  majority  of  these  conditions  we  have  already  mentioned 
with  respect  both  to  men  and  women,  and  there  remain  only  a 
few  special  cases.  The  greatest  apprehension  will  probably  be 
caused  by  a  manifest  disease  of  the  appendix,  a  condition  which 
occurs  most  often  just  at  the  age  when  marriages  are  commonly 
entered  into.  After  what  we  have  said  above  on  the  influence 
of  pregnancy  on  the  course  of  appendicitis  and  vice-versa  on  the 
effect  which  diseases  of  the  appendix  exercise  upon  gestation, 
we  should  consider  it  advisable  to  recommend  if  possible  the 
removal  of  the  appendix  before  the  consummation  of  the  mar- 
riage, especially  in  those  cases  where  the  appendicitis  has  been 
a  recurrent  one  and  where  the  danger  of  a  relapse  during  mar- 
ried life  is  therefore  particularly  great.  Whether  the  patients 
concerned  will,  especially  in  the  milder  cases,  accept  this  advice 
is  of  course  another  question.  This  applies  to  even  a  greater 
extent  in  the  case  of  gall-stones,  an  affection  which  is  hardly 
likely  ever  to  assume  such  serious  proportions  as  to  render  it 
an  insurmountable  obstacle  to  matrimony.  Lighter  cases  cer- 
tainly offer  no  sufficient  reason  for  dissuading  from  marriage, 
and  in  the  severer  ones  the  operation  spontaneously  becomes 
such  a  prominent  necessity  that  it  is  bound  to  be  carried  out 
before  the  contraction  of  marriage  almost  in  the  natural  course 
of  events. 

Matters  are  not  much  different  in  ulcer  of  the  stomach.  We 
often  see  in  our  consulting-rooms  patients  who  desire  to  be 
cured  of  a  manifest  ulcus  ventriculi,  or  of  complaints  which 
suggest  more  or  less  forcibly  the  existence  of  that  affection, 
in  time  to  get  married,  if  possible  on  the  date  fixed  beforehand 
as  the  wedding-day.  That  such,  and  let  us  add,  similar  other, 


DISEASES  OF  THE  ORGANS  OF  DIGESTION    439 

diseases  and  complaints  are  no  obstacles  to  marriage  is  clear. 
If  at  all  indicated,  it  is  advisable  to  recommend  in  such  cases 
a  postponement  of  the  marriage,  but  a  long  experience  has 
taught  me  not  to  expect  that  this  recommendation  will  be 
listened  to,  salutary  though  it  is.  The  parties  concerned  prefer 
to  take  the  risk  in  the  hope,  which  is  indeed  often  justified,  that 
marriage  will  bring  along  with  it  the  necessary  care  and 
attention. 


XIII 

Diseases    of    the    Kidneys    in    Relation    to 

Marriage 


XIII 


DISEASES  OF  THE  KIDNEYS   IN  RELATION 
TO  MARRIAGE 

By  P.  F.  Richter,  M.D.  (Berlin) 

The  kidneys  occupy  a  most  prominent  position  among  the 
organs  the  condition  of  which  is  of  the  highest  importance  with 
regard  to  the  contraction  of  marriage,  and  which  are  on  the  one 
hand  subject  to  considerable  influence  from  the  married  state 
and  on  the  other  hand  of  material  import  to  the  married  couple 
as  well  as  to  their  offspring.  To  begin  with,  the  close  spacial 
relations  existing  between  the  urinary  and  the  genital  organs 
both  in  the  male  and  female  sexes  point  to  the  possibility 
of  reciprocal  influence  between  them  through  the  medium  of 
sexual  intercourse.  Moreover  in  the  female,  pregnancy  and 
parturition  cause,  particularly  to  the  kidneys,  an  increased 
amount  of  work,  and  there  is  also  no  doubt  that  an  organ  of 
such  physiological  importance  as  the  kidney  which  makes  itself 
felt  over  the  entire  organism  even  under  normal  circumstances, 
must  necessarily  play  an  even  greater  role  when  it  is  subject  to 
disease. 

In  considering  the  reciprocal  influences  which  marriage  and 
renal  disease  exercise  upon  one  another,  it  cannot  be  our  object 
to  examine  these  relations  in  detail  with  respect  to  every  single 
disease  of  the  kidneys.  For,  apart  from  the  circumstance  that 
such  an  examination  with  its  inevitable  repetitions  would  prove 
tiresome,  a  number  of  renal  diseases  are  so  rare  that  they  hardly 
deserve  to  be  included  in  an  article  intended  in  the  first  instance 
for  the  general  practitioner.  It  must  rather  be  our  aim  to 
single  out  those  groups  of  diseases  which  are  on  the  one  hand 
of  importance  on  account  of  their  frequency  in  general  practice, 


444  HEALTH,  DISEASE,  MARRIAGE 

and  on  the  other  so  analogous  in  their  manner  of  influencing 
the  activity  of  the  kidneys  that  they  may  be  discussed  under 
one  head,  in  spite  of  their  individual  differences. 


Nephritis. 

The  medical  practitioner  who  is  asked  for  his  opinion 
whether  in  the  presence  of  nephritis  in  one  or  the  other  of  the 
parties  contemplating  marriage — for  it  is  hardly  necessary  to 
dwell  at  any  great  length  upon  the  fact  that  it  is  in  the  nature 
of  things  principally  chronic  and  not  acute  diseases  which  will 
confront  us  in  this  connection — such  marriage  is  permissible, 
must  first  ask  himself  upon  what  factors  the  diagnosis  of 
nephritis  is  based,  and  whether  this  diagnosis  is  at  all  justified. 
An  examination  of  the  urine  for  albumen  simply  is  in  any  case 
not  sufficient.  Since  we  know  that  there  is  a  so-called  physio- 
logical albuminuria,  that  is,  that  under  certain  circumstances 
an  albuminuria  may  exist  for  many  years  without  doing  any 
injury  to  the  general  health  and  without  producing  any  demon- 
strable anatomical  changes,  and  since  it  is  a  fact  that  those 
who  are  subject  to  this  condition  may  reach  the  allotted  span  of 
life,  it  would  be  perfectly  unreasonable  to  condemn  an  indi- 
vidual to  celibacy  simply  because  of  this  existing  albuminuria. 
It  is  true  that  there  may  be  very  great  difficulty  in  deciding  in 
individual  cases  whether  the  albuminuria  is  physiological  or 
not,  and  in  view  of  the  enormous  importance  of  the  subject  and 
of  the  great  responsibility  arising  to  the  physician  from  an 
answer  in  the  affirmative  we  must  consider  this  point  somewhat 
minutely. 

Differential  diagnosis  between  nephritis  and 
physiological  albuminuria. — The  first  essential  is  the 
principle  upon  which  Senator  particularly  has  always  insisted, 
namely  that  physiological  albuminuria  cannot  and  must  not 
be  diagnosed  from  a  single  examination  of  the  urine  or  even 
after  a  short  observation  only.  Most  calamitous  mistakes 
through  the  confusion  of  insidious  nephritis  with  intermittent 
albuminuria  and  without  effect  upon  the  general  state  of  health 


DISEASES  OF  THE  KIDNEYS  445 

as  without  prominent  symptoms  are  apt  to  occur  if  this  principle 
is  neglected. 

For  the  avoidance  of  such  mistakes  we  have  a  number  of 
guiding  factors  referring  above  all  to  the  condition  of  the  urine. 
It  is  not  either  the  quantity  of  urine  or  the  quantity  of  albumen 
excreted  which  comes  into  consideration,  although  the  latter 
does  so  in  one  particular  direction,  since  very  considerable 
quantities  of  albumen  may  be  said  to  exclude  with  absolute 
certainty  the  presence  of  a  physiological  albuminuria.  A  small 
quantity  of  albumen  on  the  other  hand,  say  under  0.5%,  is  not 
necessarily  harmless  because  we  often  come  across  cases  of 
chronic  nephritis  in  which  the  amount  of  albumen  in  the  urine 
continues  for  years  to  be  so  trifling  that  it  can  only  be  detected 
by  the  most  delicate  testing  methods. 

More  important  than  the  amount  is  the  course  of  the  secre- 
tion of  albumen.  Constant  albuminurias  even  if  they  are  of 
an  insignificant  nature  are  probably  never  reckoned  among 
the  physiological  ones.  The  type  of  the  latter  is  rather  the 
intermittent  variety,  observed  occasionally  in  chronic  nephritis 
as  well,  which  is  particularly  characteristic  in  those  cases  where 
definite  irritations  of  the  daily  life  lying  within  the  borders 
of  physiological  conditions  bring  the  albuminuria  into  existence, 
where  with  their  disappearance  the  albuminuria  also  disappears 
and  where  in  their  absence  no  albuminuria  occurs.  Among 
these  physiological  factors  which  favour  the  passage  of  albumen 
into  the  urine  in  individuals  specially  predisposed  to  it,  is  to 
be  reckoned  in  the  first  place  fatiguing  physical  exercise,  which 
is  associated  with  intense  muscular  activity,  sometimes  only  the 
standing  posture;  further,  irritations  from  the  sensory  sphere 
such  as  psychical  emotions  and  mental  exertions,  and  finally 
cold  baths  and  food  rich  in  albumen. 

Where  in  addition  to  the  albumen  the  urine  contains 
abnormal  constituents,  principally  leucocytes  which  do  not  come 
from  the  urinary  organs,  and  casts,  even  in  very  minute  quanti- 
ties, the  diagnosis  of  physiological  albuminuria  is  absolutely 
out  of  the  question.  The  only  exception  is  formed  by  the  pres- 
ence of  isolated  hyaline  casts  which  have  occasionally  been 
observed  along  with  the  albumen  and  also  without  the  latter 


446  HEALTH,  DISEASE,  MARRIAGE 

in  the  urine  of  healthy  people  (Cylindruria).  Nevertheless 
the  occurrence  of  more  than  a  few  isolated  specimens  of  this 
kind  will  cause  the  careful  physician  to  be  on  his  guard,  and 
induce  him  to  suspect  a  different  pathological  origin  even  where 
there  are  other  elements  pointing  to  a  physiological  albuminuria, 
and  this  suspicion  will  become  a  certainty  if  there  are  also 
found  leucocytes  (mostly  mono-unclear)  or  other  cellular  ele- 
ments as  signs  of  a  renal  affection. 

The  most  important  point  however  is  the  attitude  and  con- 
stitution of  the  individual  concerned.  Only  in  the  case  of 
younger  people  in  their  best  years  and  in  full  vigour,  without 
subjective  and  objective  signs  of  disease,  especially  of  the 
organs  of  circulation,  is  it  permissible  to  regard  an  albuminuria 
to  which  the  above  remarks  apply  as  a  comparatively  unim- 
portant symptom.  An  albuminuria  ensuing  the  other  side  of 
the  third  decade  should  never  be  classed  as  a  physiological  one, 
but  must  always  create  a  suspicion  that  there  is  an  insidious 
renal  affection  present,  even  though  all  other  symptoms  are 
absent. 

Albuminuria  of  puberty. — If  it  is  therefore  necessary 
for  the  physician  to  be  careful  in  the  interpretation  of  albumi- 
nuria in  the  case  of  somewhat  older  candidates  for  marriage 
and  to  express  an  opinion  with  a  certain  amount  of  reservation 
only,  this  cautiousness  is  none  the  less  indicated  in  those  cases 
where  we  are  in  the  presence  of  the  so-called  albuminuria  of 
puberty  which  affects  younger  individuals.  As  is  well-known 
this  is  an  occurrence  which  we  meet  in  overgrown  and  ill-devel- 
oped persons,  mostly  chlorotic  girls,  who  exhibit  all  kinds  of 
symptoms  generally  associated  with  chlorosis,  such  as  a  pale 
complexion,  a  tendency  to  tire  easily,  gastric  disturbances,  head- 
ache, etc.  Upon  examining  the  urine  incidentally  albumen  is 
found  to  be  present.  This  happens  as  a  rule  intermittently, 
especially  in  connection  with  the  urine  passed  during  the  day; 
the  condition  grows  worse  under  the  influence  of  the  factors 
enumerated  above,  particularly  the  muscular  exertions ;  the  albu- 
men is  absent  in  the  night-urine  and  diminishes  also  in  the  day- 
time or  disappears  even  altogether  when  the  patient  takes  a 
rest  in  bed. 


DISEASES  OF  THE  KIDNEYS  447 

Under  no  circumstances  must  this  kind  of  albuminuria  be 
regarded  as  a  perfectly  harmless  one.  In  the  majority  of  cases  it 
depends  probably  upon  a  poor  constitution  of  the  blood  with  light 
forms  of  cardiac  insufficiency,  the  heart  not  being  as  yet  fully 
equal  to  the  greater  demands  made  upon  it  on  the  part  of  the 
rapidly  growing  organism.  With  the  improvement  in  the 
anaemia  and  the  gradual  increase  in  the  activity  of  the  heart 
the  albuminuria  may  disappear  permanently. 

There  are  however  sufficient  observations  known  where  the 
albuminuria  of  puberty  formed  the  starting-point  or  rather  the 
first  manifestation  of  an  insidious  nephritis  and  where  the  pro- 
nounced complex  of  symptoms  of  chronic  nephritis  developed 
fully  after  many  years  without  any  other  cause. 

Just  because  as  already  mentioned  it  is  chiefly  young  girls 
who  exhibit  such  albuminurias  the  acquiescence  in  the  contrac- 
tion of  marriage  involves  in  such  cases  a  certain  responsibility 
on  the  part  of  the  medical  attendant.  Pregnancy  and  labour 
impose  such  a  considerable  task  on  even  healthy  kidneys,  that 
kidneys  whose  parenchyma  is  without  doubt  on  account  of 
deficient  circulation  and  bad  nutrition  less  capable  to  resist 
unusual  irritation  than  under  normal  circumstances  appear 
indeed  to  be  in  danger;  nor  is  it  by  any  means  impossible  for 
this  condition  to  grow  into  a  genuine  nephritis  in  the  course 
of  one  or  several  pregnancies.  At  any  rate  the  physician  will 
endeavour,  before  the  marriage  is  consummated,  to  bring  the 
albuminuria  to  an  end  by  the  employment  of  the  usual  thera- 
peutic remedies,  such  as  iron  preparations,  stimulation  of  the 
activity  of  the  heart,  and  similar  other  measures.  On  the 
other  hand  it  is  not  necessary  in  such  cases  to  look  upon  the 
situation  with  too  much  pessimism  but  to  recollect  that  fre- 
quently where  all  these  remedies  fail,  marriage  acts  as  a  real 
cure  of  the  chlorosis  and  consequently  of  the  principal  cause  of 
the  albuminuria.  (See  chapter  on  chlorosis  for  further  details.) 

We  could  do  no  more  on  this  occasion  than  point  out  in 
brief  the  factors  which  help  us  to  decide  the  question  whether 
in  any  given  case  of  albuminuria  we  have  before  us  an  undoubted 
chronic  nephritis  or  a  comparatively  less  serious  disturbance  in 
the  health  of  the  individual  concerned.  At  any  rate  it  must 


448  HEALTH,  DISEASE,  MARRIAGE 

be  emphasized  how  difficult  the  diagnosis  may  be  in  any  single 
case  and  that  it  can  only  be  arrived  at  after  a  most  minute 
consideration  of  the  various  circumstances,  and  after  a  pro- 
longed period  of  observation.  For  this  reason  there  is  no  one 
better  qualified  to  express  a  definite  opinion  on  the  point  than 
the  family  doctor  who  has  known  and  observed  the  candidate 
for  marriage  perhaps  from  childhood  or  at  any  rate  for  some 
time,  and  who  is  perfectly  familiar  with  his  or  her  early  life, 
previous  diseases,  constitution  and  other  such  momentous  details. 
It  is  hardly  necessary  in  view  of  what  has  been  said  above,  to 
enlarge  on  the  importance  of  this  first-hand  information.  That 
mistakes  are  apt  to  occur  in  spite  of  most  careful  observations 
is  proved  by  the  statistics  of  physicians  to  life-insurance  offices. 
Thus  Washbourn  has  seen  of  39  insured  with  supposed  "physio- 
logical albuminuria"  only  about  half  the  number  reach  the 
normal  average  duration  of  life.  And  even  Leube  who  has 
more  than  anyone  else  pointed  out  the  comparative  frequency 
of  albuminuria  in  otherwise  healthy  individuals  admits  that  he 
has  in  the  course  of  time  become  more  careful  in  excluding 
nephritis  in  apparently  harmless  cases  of  albuminuria.  At  any 
rate  there  will  always  be  cases  where  the  physician  consulted 
will  be  in  a  position  to  assure  the  person  contemplating  matri- 
mony that  his  or  her  albuminuria  is  to  all  appearances  of  no 
consequence  and  that  it  does  not  constitute  an  obstacle  to  con- 
traction of  marriage,  although  it  may  act  as  a  warning  to  be 
careful  about  the  mode  of  life  to  be  adopted.  This  optimistic 
view  of  the  situation  is  often  thoroughly  confirmed  by  the 
further  course  of  the  individual's  married  life. 

By  far  the  preponderating  majority  of  cases  of  albuminuria, 
however,  depend  upon  chronic  nephritis,  and  we  have  now  to 
consider  the  influence  of  marriage  upon  the  course  of  inflamma- 
tion of  the  kidneys,  and  in  this  connection  to  examine  carefully 
into  the  question  whether  and  under  what  circumstances  the 
contraction  of  marriage  may  be  permitted  from  the  medical 
standpoint  in  the  presence  of  nephritis  in  the  one  or  the  other 
party. 

It  is  in  the  first  instance  necessary  to  remember — and  this 
is  a  point  which  applies  equally  to  both  sexes — that  chronic 


DISEASES  OF  THE  KIDNEYS  449 

nephritis  per  se,  that  is  without  regard  to  the  married  state, 
shortens  materially  the  duration  of  life.  It  is  true  that  we  no 
longer  estimate  the  probable  life-duration  of  nephritic  patients 
with  such  pessimism  as  was  done  by  older  generations  of 
medical  men  who  frequently  did  not  diagnose  the  disease  until 
it  had  reached  its  final  stages.  We  know  that  patients  with 
so-called  cirrhotic  kidney  can  from  the  perfectly  insidious  begin- 
ning onwards  live  and  follow  their  occupations  comparatively 
free  from  symptoms  and  complaints  for  as  long  as  20  years 
and  more.  But  opposed  to  this  relatively  prolonged  and  favour- 
able course  of  the  disease  with  more  or  less  extended  intervals 
of  remission  we  have  as  the  other  side  of  the  picture  what 
we  may  fairly  call  the  absolute  incurability  of  the  malady. 

The  influence  of  the  married  state  upon  the  course  and 
duration  of  the  illness  does  not  manifest  itself  similarly  in 
men  and  women  and  it  is  therefore  requisite  to  consider  it 
separately  with  respect  to  each  of  the  two  sexes. 

Influence  of  marriage  on  the  chronic  nephri- 
tis of  the  husband. — Married  life  does  not  appear  to 
possess  any  elements  which  act  aggravatingly  upon  the  nephri- 
tis of  the  husband.  No  doubt  every  physician  has  not  infre- 
quently opportunities  to  observe  in  men  cases  of  nephritis  which 
have  hitherto  remained  latent  and  unrecognised  and  which 
assume  soon  after  marriage  a  rapid  character  leading  to  a 
fatal  issue  in  a  comparatively  short  time.  It  is  certainly  pos- 
sible that  this  rapid  course  is  rendered  still  more  so  in  conse- 
quence of  the  reproaches  which  the  patient  makes  himself, 
since  we  know  from  experience  that  psychical  emotions  influence 
nephritis  most  injuriously.  Generally  speaking  however  it  is 
not  the  married  state  as  such  which  is  accountable  for  the 
aggravation,  but  external  contingent  circumstances.  Where 
the  struggle  for  the  daily  bread  makes  life  harder,  where  the 
husband  in  order  to  maintain  his  family  has  to  perform  a 
greater  amount  of  work  after  his  marriage  than  he  did  when 
he  was  single,  the  nephritis  is  sure  to  find  a  suitable  soil  for 
further  and  rapid  development,  especially  if  there  is  no  possi- 
bility for  the  struggling  and  afflicted  patient  to  take  care  of 
himself  or  to  obtain  the  proper  nursing. 


450  HEALTH,  DISEASE,  MARRIAGE 

Where  the  outward  circumstances  are  however  favourable, 
where  the  necessary  comforts  of  life  can  easily  be  obtained, 
where  exacting  employment  can  be  avoided,  where  it  is  possible 
to  seek  in  the  winter  a  refuge  in  suitable  southern  climates  and 
where  similar  other  luxuries  can  be  indulged  in ;  further,  where 
a  regulated  mode  of  life  does  not  offer  opportunities  for  ex- 
cesses of  any  kind,  and  where  the  nutrition  is  wholesome  and 
less  irritating  for  the  kidneys  than  the  restaurant-food  of 
bachelors  generally  is — under  these  circumstances  the  renal 
affection  is  more  likely  to  be  influenced  beneficially  and  the 
married  state  more  likely  to  prove  life-prolonging. 

As  to  the  character  of  the  married  life,  and  especially  with 
regard  to  the  gratification  of  the  sexual  activity  and  the  possi- 
bility of  propagation,  it  is  certainly  true,  that  chronic  nephritis 
is  in  so  far  injurious  as  it  is  reckoned  among  those  diseases 
which  lead  in  the  course  of  time  to  a  diminution  of  the  virile 
power.  This  influence  must  not  however  be  exaggerated.  In 
the  far-advanced  stages,  when  cachexia  is  well-marked,  when 
all  vegetative  functions  are  at  a  standstill,  when  the  unhappy 
and  exhausted  patients  are  but  the  shadows  of  their  former 
selves,  complete  absence  of  the  sexual  desire  is  the  rule.  But 
on  the  other  hand  experience  tells  that  during  the  latent  stages 
which  may  last  for  years  and  even  decades  and  in  the  course 
of  which  the  disease  manifests  itself  by  traces  of  albumen  only, 
there  is  generally  no  pronounced  impotence  such  as  would 
attract  the  attention  of  the  patients,  and  they  are  capable  of 
doing  full  justice  to  their  marital  obligations.  There  are  cer- 
tainly exceptions  to  this  rule.  Bartels  as  well  as  Fiirbringer 
point  out  that  a  "mysterious"  diminution  of  the  facultas  coeundi 
occurs  sometimes  at  a  very  early  stage  of  chronic  interstitial 
nephritis. 

Influence  of  marriage  on  the  nephritis  of 
the  wife. — Of  far  greater  importance  than  in  men,  are  the 
relations  between  marriage  and  nephritis  in  women,  since  preg- 
nancy and  childbirth, — particularly  the  former — exert  a  most 
complicated  influence  upon  the  activity  of  the  kidneys  and  its 
disturbances.  The  effect  of  the  married  state  upon  the  nephritis 
of  the  wife  is,  to  begin  with, — and  this  applies  equally  to  all 


DISEASES  OF   THE  KIDNEYS  451 

the  other  diseases  of  the  kidneys,  of  which  we  shall  speak  later 
on — far  more  lasting  and  fateful  than  upon  that  of  the 
husband.  For  this  reason  it  is  also  easy  to  understand  how  it 
is  that,  whereas  casuistic  contributions  to  the  subject  "marriage 
and  nephritis"  in  regard  to  man  are  very  rare  and  deal  at  the 
utmost  with  a  diminution  in  the  virile  power,  the  same  question 
with  regard  to  woman  is  represented  in  literature  by  a  consider- 
able number  of  cases  recording  the  influence  of  pregnancy,  par- 
turition and  child-bed  upon  diseases  of  the  kidneys  of  which 
nephritis  is  by  far  the  most  prominent.  The  most  recent  com- 
prehensive work  dealing  with  the  subject,  that  of  Fellner,  men- 
tions no  less  than  740  publications  which  are  more  or  less 
connected  with  this  question,  though  most  of  these  are  written 
more  from  the  point  of  view  of  the  gynaecologist  and  obstetri- 
cian than  from  that  of  the  family  practitioner.  We  must  to 
a  certain  extent  agree  with  Fellner  when  he  points  to  the  con- 
tradiction that  in  spite  of  the  voluminous  appreciation  of  the 
subject  in  the  specialist  gynaecological  literature  most  recent 
contributions  on  nephritis  omit  either  all  reference  to  the  influ- 
ence of  renal  diseases  in  connection  with  pregnancy  and  vice- 
versa  that  of  pregnancy  in  relation  to  existing  renal  disease, 
or  mention  it  only  very  briefly. 

In  discussing  this  influence — as  already  mentioned  preg- 
nancy occupies  in  this  connection  the  foremost  place  whilst 
labour  and  child-bed  are  only  of  secondary  importance — we 
must  keep  the  two  following  points  apart  from  one  another: 
i.  Renal  disease  in  association  with  or  as  a  consequence  of 
pregnancy.  2.  Pregnancy  in  association  with  previously  exist- 
ing renal  disease.  It  will  be  our  aim  to  show  that  we  have  here 
two  prognostically  different  conditions  which  vary  also  with 
regard  to  the  dangers  which  they  occasion  to  the  mother  and 
the  offspring. 

Nephritis  of  pregnancy. —  i.  As  regards  the  renal 
disorders  which  are  dependent  on  pregnancy  as  such  it  is  usual 
to  call  them  by  the  name  of  "nephritis  of  pregnancy."  We 
understand  by  the  same  an  affection  of  the  kidneys  arising  dur- 
ing pregnancy,  usually  in  its  latter  months,  in  persons  who  have 
never  previously  suffered  from  any  disturbances  in  the  domain 


452  HEALTH,  DISEASE,  MARRIAGE 

of  the  urinary  organs.  Diagnostically  it  is  not  always  easy  to 
differentiate  the  condition  from  simple  congestion,  and  in  going 
through  the  literature  of  the  subject  one  frequently  meets  cases 
quoted  as  nephritis  which  do  not  really  belong  to  this  classifi- 
cation. The  urine  is  rich  in  albumen,  contains  numerous 
abnormal  constituents,  casts,  leucocytes,  fatty  renal  epithelium; 
the  appearance  and  concentration  of  the  urine  may  be  variable ; 
sometimes  it  is  pale  and  copious  with  a  low  specific  gravity, 
sometimes  especially  in  consequence  of  co-existent  congestion, 
of  high  specific  gravity  and  scanty.  In  addition,  there  exist 
other  signs,  more  or  less  pronounced,  of  acute  nephritis :  oedema, 
dropsy,  not  infrequently  retinitis,  and  finally  eclampsia. 

The  origin  of  the  affection  is  by  no  means  clear ;  clear  is  only 
its  relation  to  pregnancy.  But  in  what  manner  the  latter  creates 
the  nephritis — on  this  point  opinion  is  very  much  divided.  Some 
authors  suppose  it  is  due  to  a  pressure-congestion ;  some  assume 
a  parasitic  nephritis.  According  to  v.  Leyden  there  is  no  direct 
inflammatory  process,  but  only  an  anaemia  of  the  kidneys  with 
fatty  degeneration.  Senator  agrees  with  those  authors  who 
attribute  the  injury  to  the  kidneys  to  a  retention  of  poisonous 
substances  in  the  blood,  a  toxaemia  resulting  from  deficient  renal 
activity.  The  causation  would  therefore  lie  in  an  insufficient 
"detoxication"  of  the  body,  and  such  a  condition  is  in  fact  more 
likely  to  arise  during  pregnancy  than  at  other  times,  partly  on 
account  of  the  considerably  increased  work  thrown  upon  the 
kidneys,  partly  in  consequence  of  mechanical  pressure  and 
encroachment  of  space  in  the  abdomen  by  the  pregnant  uterus, 
and  partly  in  consequence  of  a  greater  production  of  toxic  sub- 
stances in  the  general  metabolism  of  the  pregnant  woman. 

More  important  than  the  points  of  view  indicated  above 
with  regard  to  the  pathogenesis  are  for  practical  reasons  the 
following  questions: 

1)  What  is  the  frequency  of  the  condition  designated  as 
nephritis  of  pregnancy? 

2)  Is  there  in  the  condition  of  the  kidneys  preceding  the 
pregnancy  an  clement  which  predisposes  to  nephritis,  in  other 
words,  can  the  latter  be  foretold  beforehand  or  can  its  super- 
vention be  prevented  in  any  way? 


DISEASES  OF   THE  KIDNEYS  453 

3)  Which  are  the  dangers  arising  to  the  mother  from  the 
nephritis  ? 

4)  How  can  we,  as  far  as  is  possible,  circumvent  these 
dangers  ? 

1 )  The  frequency  of  nephritis  in  pregnancy  is  not  a  very 
great  one.     The  different  statistics  vary  somewhat  from  each 
other,  but  nevertheless  it  does  not  exceed  10%.    Thus  Mynlief 
gives   245    cases   "with   albuminuria"   out   of   3536   pregnant 
women.     Fischer  finds  only  7.4%.     We  mention  these  two 
authors  as  examples  merely.     From  none  of  the  statistics  how- 
ever does  it  appear  definitely  whether  they  always  refer  to 
genuine  nephritis  of  pregnancy  only,  and  whether  simple  cases 
of  congestion  are  not  included. 

2)  As  to  predisposing  moments  which  are  of  importance 
for  the  origin  of  gestation-nephritis  we  know  next  to  nothing. 
Most  authors  endeavour  to  get  over  the  difficulty  by  the  sup- 
position of  a  "deterioration"  of  the  kidneys  which  causes  them 
to  respond  much  more  intensively  to  the  retained  toxic  sub- 
stances than  healthy  organs.      If,   to  begin  with,   there  is  in 
addition  to  this  deterioration  a  certain  inefficiency  in  the  excret- 
ing capacity,  the  result  is  naturally  a  constantly  increasing  over- 
loading of  the  blood  with  effete  material,  thus  creating  a  proper 
vicious  circle.    These  are  however  so  far  but  mere  suppositions 
without  a  definite  clinical  or  experimental  basis.     It  ought  to 
be   demonstrated   in   the   first   instance   whether   women   with 
"physiological"  albuminuria  or  women  exhibiting  the  higher 
degrees  of  renal  injury  which  we  have  considered  under  the 
heading  of  "albuminuria  of  puberty"  are  more  apt  to  suffer 
from   pregnancy-nephritis  than   other  women.      As   far  as   I 
know  there  are  no  observations  in  that  direction  which  might 
be  of  assistance  to  the  practitioner  in  arriving  at  a  decision. 

It  is  nevertheless  advisable  in  such  cases  to  be  careful  with 
the  prognosis,  and  if  not  exactly  to  oppose  the  marriage,  at 
least  to  call  attention  to  a  possible  complication  of  pregnancy 
with  nephritis.  It  will  also  be  the  duty  of  the  medical  attendant 
to  watch  the  woman  in  question  most  attentively,  and  to  satisfy 
himself  by  repeated  examinations  of  the  urine  as  to  the  state 
of  the  kidneys,  so  as  to  be  able  to  take  immediately  the  neces- 


454  HEALTH,  DISEASE,  MARRIAGE 

sary  steps  and  to  recommend  the  necessary  conduct  as  soon  as 
the  first  symptoms  of  a  disordered  renal  activity  make  their 
appearance. 

Transition  of  pregnancy -nephritis  into 
chronic  nephritis. —  3)  Among  the  dangers  resulting  to 
the  mother  from  the  nephritis  of  pregnancy  we  have  to  consider 
in  the  first  place  the  question  whether  a  temporary  condition 
existing  during  the  time  of  pregnancy  and  disappearing  with 
its  conclusion  may  pass  into  a  permanent  renal  affection,  i.  e., 
a  chronic  nephritis,  and  whether  such  a  transition  occurs  fre- 
quently, if  it  occurs  at  all? 

The  answer  to  these  questions  varies.  According  to  some 
authors  (Fehling,  Flaischlen,  Freyhan,  Hahn,  Lohlein,  Studer, 
and  others)  the  danger  of  such  a  transition  does  not  exist  at 
all,  or  else  to  such  an  insignificant  extent  that  it  is  not  of  any 
practical  importance.  In  their  opinion  the  nephritis  of  preg- 
nancy has  always  a  tendency  to  heal;  but  sometimes,  though 
rarely,  the  condition  is  apt  to  return  with  subsequent  pregnan- 
cies. Hofmeier  also,  contrary  to  his  own  former  opinion,  is 
now  on  the  side  of  those  who  consider  the  transition  into  chronic 
nephritis  as  at  least  not  proved,  and  who  rightly  miss  in  the 
statistics  which  answer  the  question  in  the  affirmative  at  the 
hand  of  figures,  positive  evidence  that  the  women  concerned 
were  as  a  matter  of  fact  previously  in  the  possession  of  per- 
fectly healthy  kidneys.  For  this  reason  such  statistics  as  that  of 
Koblanck  which  gives  6.$%  as  the  frequency  of  the  occurrence 
of  chronic  nephritis  after  pregnancy-nephritis,  are  not  quite 
without  faults.  For  they  omit  to  give  the  state  of  the  patients 
before  their  first  pregnancy.  Besides,  hospital  material  upon 
which  these  figures  are  based  is  altogether  the  least  suitable 
for  the  purpose,  seeing  that  it  consists  of  a  class  of  people  who 
are  not  in  a  position  to  look  after  themselves  very  carefully,  who 
do  not  often  undergo  medical  examination  and  in  whom  a 
chronic  nephritis  is  more  likely  to  be  overlooked  than  among 
the  better  classes  who  are  constantly  under  the  medical  super- 
vision of  their  family  attendants. 

But  although  numerical  evidence  as  to  the  frequency  with 
which  chronic  nephritis  develops  from  the  nephritis  of  preg- 


DISEASES  OF  THE  KIDNEYS  455 

nancy  is  not  obtainable,  there  can  be  no  doubt  as  to  the  possi- 
bility of  such  an  occurrence.  This  is  proved  by  cases  reported 
by  v.  Leyden,  Wembaum  and  Herrlich,  which  were  observed 
in  Prof.  v.  Ley  den's  clinic;  further  by  Krzyminski,  Puech, 
Westerode  and  others. 

Under  what  circumstances  this  transition  takes  place,  what 
factors  favour  its  occurrence,  are  points  which  the  clinical 
observations  do  not  show  at  all  clearly;  neither  can  we  derive 
any  information  from  anamnestic  data,  nor  is,  as  Koblanck  truly 
observes,  the  beginning  and  duration  of  the  renal  trouble  at 
all  characteristic  so  as  to  be  of  any  help.  In  spite  of  a  long 
duration  of  the  albuminuria  in  pregnancy-nephritis  it  is  possible 
for  chronic  nephritis  to  remain  absent;  on  the  other  hand  it 
may  make  its  appearance  subsequently  during  a  comparatively 
favourable  and  harmless  course  of  the  former,  as  has  been 
shown  by  isolated  observations,  so  that  it  is  never  possible  to 
say  beforehand  with  certainty  what  is  going  to  happen.  At  any 
rate  even  if  we  cannot  at  all  share  the  view  of  those  authors 
who  look  upon  pregnancy-nephritis  as  a  relatively  harmless 
renal  disorder  which  does  not  leave  behind  any  evil  conse- 
quences, we  can  at  least  derive  a  certain  amount  of  comfort 
from  the  reflection  that  it  but  rarely  passes  into  chronic 
nephritis. 

Nor  is  the  danger  of  a  relapse  of  pregnancy-nephritis  during 
subsequent  pregnancies  very  great.  It  does  happen — such  cases 
have  been  recorded  by  Fehling,  Flaischlen  and  others — that 
pregnancy-nephritis  occurs  in  one  and  the  same  multipara  sev- 
eral times  without  the  kidneys  showing  any  abnormal  function 
during  the  intervals  and  without,  judging  at  least  from  observa- 
tions made  hitherto,  the  development  of  a  chronic  renal  inflam- 
matory condition.  But  on  the  whole  the  repeated  occurrence 
of  pregnancy-nephritis  is  not  frequent.  Fellner  could  find 
among  the  large  material  of  Prof.  Schauta's  clinic  only  4  such 
cases.  As  a  rule  pregnancy-nephritis  occurs  in  the  first  preg- 
nancy only,  and  is  absent  in  the  subsequent  ones,  partly  in  con- 
sequence of  hypertrophy  of  the  heart  becoming  more  and  more 
established  with  every  pregnancy,  partly,  as  some  believe  on 
account  of  the  kidneys  getting  gradually  accustomed  to  the 


456  HEALTH,  DISEASE,  MARRIAGE 

toxins  forming  in  the  pregnant  organism,  and  partly  also  because 
the  intra-abdominal  crowded  condition  becomes  less  and  less 
pronounced  with  every  fresh  gestation. 

Of  serious  dangers  to  the  mother  must  in  the  first  instance 
be  mentioned  eclampsia;  it  threatens  the  life  of  patients  affected 
with  pregnancy-nephritis  to  a  not  inconsiderable  extent.  Fehl- 
ing  has  computed  this  to  amount  to  $%.  In  addition  the  prema- 
ture separation  of  the  placenta  has  been  repeatedly  observed 
in  association  with  a  strong  tendency  to  haemorrhages.  As  to 
the  dangers  arising  to  the  foetus  in  consequence  of  this  we  shall 
have  something  to  say  later  on.  Finally,  affections  of  the  retina 
are  not  infrequently  an  undesirable  complication. 

The  combating  of  the  dangers  in  pregnancy- 
nephritis. —  4)  With  regard  to  the  successful  combating  of 
the  dangers  connected  with  the  nephritis  of  pregnancy,  opinion 
is  in  so  far  divided  that  the  question  arises  whether  the  inter- 
ruption of  the  pregnancy  is  indicated  and  particularly  at  what 
stage  this  operation  should  be  undertaken.  The  majority  of 
authors  are  of  the  opinion  that  we  should  at  first  for  some  time 
try  the  ordinary  therapeutic  treatment  of  nephritis  especially 
the  hygienic-dietetic  part  of  it,  and  to  see  whether  an  improve- 
ment can  thus  be  effected.  If  this  is  not  the  case,  if  the  nephritic 
symptoms  get  worse,  if  the  oedema  and  dropsy  increase,  if 
dyspnoea,  headache,  and  other  nervous  phenomena  make  their 
appearance,  and  if  the  activity  of  the  heart  is  inefficient,  the 
induction  of  premature  labour  becomes  fully  justified.  In  the 
case  of  the  above-mentioned  complications,  especially  in  eclamp- 
sia, artificial  detachment  of  the  placenta,  and  retinitis  albumi- 
nurica,  the  operative  interruption  of  the  pregnancy  must  be 
effected  as  soon  as  possible.  In  retinitis,  because  the  affections 
of  the  retina  during  pregnancy-nephritis  offer  the  best  prognosis, 
if  the  pregnancy  is  quickly  determined.  A  complete  restitutio 
ad  integrum  is  then  soonest  to  be  expected.  Even  where  the 
acuteness  of  vision  is  only  moderately  diminished  the  immediate 
induction  of  premature  labour  is  indicated.  (Silex.) 

It  must  not  however  be  concealed  that  more  radical  views 
than  the  above  have  also  been  expressed  and  that  they  also  have 
their  supporters.  Thus  for  instance  Jarret  recommends  the 


DISEASES  OF  THE  KIDNEYS  457 

immediate  induction  of  premature  labour  under  all  circum- 
stances; he  refuses  to  wait  until  the  7th  month,  that  is  up  to 
the  time  when  the  foetus  is  viable,  on  account  of  the  supposed 
bad  prognosis  of  the  child's  life  and  because  of  the  dangers 
which  a  prolonged  continuation  of  the  albuminuria  is  likely 
to  cause  to  the  mother.  Some  German  authors  also  take  up 
the  standpoint  that  the  induction  of  the  premature  labour  with- 
out waiting  for  any  length  of  time  is  indicated  if  the  pregnancy- 
nephritis  leads  already  to  symptoms  in  the  first  half  of  the 
pregnancy. 

We  must  of  course  ask  ourselves:  Is  there  any  chance  of 
diminishing  or  removing  entirely  the  dangers  threatening  the 
life  of  the  mother,  at  least  in  so  far  as  simple  uncomplicated 
nephritis  is  concerned,  by  means  of  this  more  active  interfer- 
ence ?  For,  as  regards  eclampsia  and  similar  immediately  dan- 
gerous complications  there  can  be  no  two  opinions.  Even 
authors  like  v.  Leyden  who  incline  to  the  view  that  the  longer 
albuminuria  lasts  the  more  its  dangers  grow,  admit  that  we 
have  absolutely  no  criteria  by  which  we  can  judge  whether  we 
may  hope  for  its  disappearance  after  a  certain  time  or  on  the 
other  hand  fear  its  prolonged  continuation.  The  indications 
for  the  premature  labour  or  for  the  time  of  its  induction  are 
therefore  quite  uncertain.  And  just  as  uncertain  is  the  desired 
result. 

Besides,  the  interruption  of  the  pregnancy  is  by  no  means 
an  absolutely  safe  procedure.  Kleinwachter  and  Schauta  are 
right  in  pointing  out  that  the  existing  dangers  are  not  imme- 
diately removed  by  the  induction  of  premature  labour  and  that 
on  the  contrary  greater  ones  may  sometimes  be  created,  seeing 
that  the  labour  process  in  itself  supplies  a  fresh  complicating 
factor.  "The  difference  between  the  point  of  view  of  the 
internal  clinician  and  that  of  the  gynaecologist  is  that  the  former 
devotes  special  attention  to  pregnancy  in  its  evil  effect  upon  an 
existing  internal  disease,  whilst  the  latter  takes  into  considera- 
tion the  rock  of  parturition  as  well."  (Schauta.} 

The  opinion  of  Schauta,  expressed  in  the  lecture  from  which 
these  sentences  are  extracted,  to  the  effect  that  "most  ailments  are 
overrated  in  their  importance  with  regard  to  pregnancy"  may 


458  HEALTH,  DISEASE,  MARRIAGE 

apply  perhaps,  as  can  be  judged  from  what  has  been  said  above, 
to  nephritis  which  supervenes  in  the  course  of  pregnancy,  but 
not  to  pregnancy  associated  with  a  previously  existing  nephritis. 
Chronic  nephritis  with  which  we  desire  to  deal  now  is  most 
unfavourably  influenced  by  pregnancy  in  by  far  the  prepon- 
derating number  of  cases.  (Dickinson,  Moricke,  Carpentier, 
v.  Leyden,  Weinbaum,  Mynlieff,  Hofmeier,  Fehling,  and 
others.)  And  it  is  chiefly  two  factors  which  are  accountable 
for  this :  firstly  the  circulatory  disturbances  caused  by  the  preg- 
nancy which  throw  more  work  upon  the  kidneys  and  influence 
injuriously  the  compensation  between  the  heart  and  the  kidneys, 
and  secondly  the  direct  damage  to  the  renal  parenchyma  pro- 
duced by  chemical  noxae.  If,  as  we  have  seen  while  considering 
the  nephritis  of  pregnancy,  the  metabolic  products  formed  in 
the  pregnant  organism  are  capable  of  injuring  a  healthy  kidney 
or  at  least  one  which  is  in  a  certain  weak  condition  of  equi- 
librium, how  much  more  likely  is  it  that  they  will  act  delete- 
riously  upon  one  already  diseased  and  inflammatorily  altered? 
As  a  matter  of  fact  we  do  not  infrequently  observe  that  renal  dis- 
turbances which  have  apparently  become  healed,  and  latent  proc- 
esses which  gave  rise  to  no  symptoms,  break  out  afresh  during 
pregnancy  and  assume  an  active  character:  the  hitherto  slight 
albuminuria  increases  in  severity;  the  urine  contains  a  more  or 
less  abundant  accession  of  epithelial  cells  and  casts;  oedemata 
appear,  the  organs  of  circulation  are  affected,  the  general  con- 
dition becomes  worse ;  in  brief  the  nephritis  which  had  hitherto 
remained  almost  unnoticed  or  at  any  rate  been  going  on  without 
injuring  the  health,  experiences  a  rapid  exacerbation  so  that  it 
is  capable  under  symptoms  of  cardiac  debility  or  of  uraemia  and 
eclampsia  to  lead  to  a  fatal  issue  at  the  very  first  pregnancy. 

In  the  whole  course  and  in  the  clinical  aspect  of  the  chronic 
nephritis  which  recrudesces  during  pregnancy  there  is  a  great 
difference  noticeable  as  against  the  nephritis  of  pregnancy.  The 
symptoms  do  not  appear  as  late  as  the  second  half  of  the  preg- 
nancy but  frequently  much  earlier;  they  can  assume  an  alarm- 
ing character  and  quickly  cause  imminent  danger  to  life.  I 
append  here  as  examples  a  few  instructive  cases  out  of  the 
casuistic  literature  on  the  subject. 


DISEASES  OF  THE  KIDNEYS  459 

1.  Case    of    Mynlieff:    Woman,    formerly    acute 
nephritis,  cured  with  the  exception  of  a  few  remain- 
ing symptoms,   becomes  pregnant.      During  the  preg- 
nancy increase  in  the  hitherto  small  quantity  of  albumen 
in  the  urine.     The  latter  contains  numbers  of  hyaline 
casts  and  epithelial  cells.     CEdemata.     Retinitis  albu- 
minurica.     Birth  of  a  macerated  foetus.    Three  months 
later  death. 

2.  Case  of  Lohlein.      (Transition  of  pregnancy- 
nephritis   into   chronic   nephritis.)      A  woman,    thirty 
years  of  age  is  taken  ill  in  the  yth  month  of  her  7th 
pregnancy  with  nephritic  symptoms.     Artificial  prema- 
ture labour.     Material  improvement,  but  no  complete 
subsidence  of  the  nephritis.     One  year  later  fresh  preg- 
nancy.    In  the  5th  month  uraemic  attack.    Death. 

3.  Case  of  Pawlinoff:    Woman,  21  years  old.    At 
the  age  of   13   diphtheria  with  paralysis  of  the  soft 
palate.  Married  at  20.    In  the  course  of  the  pregnancy, 
oedemata,  headache,  uraemic  symptoms,  retinitis  albu- 
minurica,  increase  in  the  quantity  of  urine,  specific  grav- 
ity 1009,  little  albumen,  few  casts.    After  the  birth  of 
a  dead  child,  subsidence  of  the  symptoms,  but  marked 
hypertrophy  of  the  heart  and  increased  tension  of  the 
blood-vessels.     As  the  appearances  in  the  circulatory 
apparatus  show,  this  is  a  case  of  chronic  nephritis  which 
had  existed  for  some  time  and  which  has  developed 
gradually  and  insidiously,  probably  in  connection  with 
the  dipththeria  gone  through  in  childhood.     But  the 
patient  has  never  noticed  anything  wrong;  during  the 
married  state  only  and  in  consequence  of  pregnancy 
the  disease  assumed  a  serious  character  and  compensa- 
tory disturbances  soon  made  their  appearance. 

It  is  not  necessary  for  violent  symptoms  to  show  themselves 
at  the  very  first  pregnancy ;  but  even  where  the  latter  has  taken 
a  favourable  course  a  lasting  deterioration  in  the  state  of  the 
kidneys  does  not  as  a  rule  remain  wanting.  Each  following 
pregnancy  then  increases  the  dangers  and  sooner  or  later  the 
patient  is  bound  to  succumb  to  her  nephritis. 


460  HEALTH,  DISEASE,  MARRIAGE 

A  case  observed  by  v.  Leyden  and  communicated 
by  Weinbaum  illustrates  very  clearly  the  injurious  influ- 
ence of  repeated  pregnancies.  Three  normal  labours 
which  presented  no  disturbing  features  in  a  woman  with 
chronic  nephritis  are  succeeded  by  5  miscarriages  with 
a  constant  increase  in  the  renal  symptoms  from  which 
the  patient  died  during  her  last  pregnancy.  Fellner 
reports  a  case  from  Schauta's  clinic  of  a  nephritis  in  the 
course  of  which  hemiplegia  occurred  in  the  8th  month 
of  the  3d  pregnancy.  The  same  occurred  again  in  the 
9th  month  of  the  8th  pregnancy  and  led  after  induction 
of  premature  labour  to  a  fatal  issue. 

The  prognosis  of  nephritis  in  married  women  need  not 
necessarily  always  be  such  a  sad  one;  the  injurious  influence  of 
pregnancy  upon  the  disease  is  sometimes  absent.  Occasionally 
we  even  see  during  pregnancy,  as  Lohlein  points  out,  an 
improvement  or  a  complete  disappearance  of  the  nephritic 
symptoms.  Fellner  found  among  the  registers  of  births  of 
Schauta's  clinic  29  histories  recording  nephritic  phenomena 
previous  to  the  respective  pregnancies,  but  none  in  the  course 
of  the  latter.  It  must  however  be  admitted  that  they  refer 
to  simple  pregnancy-nephritis  or  to  genuine  chronic  inflamma- 
tion of  the  kidneys. 

I  myself  saw  a  lady  who  developed  a  severe  acute 
nephritis  in  1892  in  consequence  of  sepsis  and  who  mar- 
ried in  1895  contrary  to  medical  advice.  The  urine 
still  contained  then  moderate  quantities  of  albumen, 
leucocytes  and  scanty  hyaline  casts.  The  pregnancy 
took  a  perfectly  favourable  course  and  ended  with  the 
birth  of  a  living  child,  and  so  far  there  has  been  no 
aggravation  whatever  of  the  conditions;  the  state  of 
the  urine  is  still  entirely  unchanged,  and  of  other  sub- 
jective or  objective  symptoms  there  is  no  trace.  There 
has  not  however  been  another  pregnancy  since. 

Most  instructive,  as  regards  the  life-saving  influence 
of  the  interruption  of  the  pregnancy  on  the  one  hand, 
and  as  regards  the  importance  of  the  prevention  of 
pregnancies  on  the  other,  measures  by  which  a  compara- 


DISEASES  OF  THE  KIDNEYS  461 

tively  favourable  course  of  the  renal  affection  has  been 
achieved,  is  the  following  case  of  Senator: 

Woman,  pregnant  12  years  ago.  Nephritis.   Prema- 
ture labtmr.    After  two  years  fresh  pregnancy.     In  the 
course  of  the  latter  hemiplegia  of  the  right  side.     The 
pregnancy  is  interrupted.     Since  that  time  conception 
has  been  prevented.     The  hemiplegia  is  at  the  moment 
almost  entirely  gone;  the  nephritis  has  made  no  prog- 
ress; the  urine  contains  only  slight  traces  of  albumen. 
It  must  certainly  be  admitted  that  the  consideration  of  the 
subject  on  the  strength  of  hospital  material  exclusively,  sup- 
plies  a   rather  gloomy  picture,   since  that  material  generally 
consists  of  the  severest  cases  only  and  is  recruited  from  a  class 
of  people  who  are  not  in  a  position  before  and  during  pregnancy 
to  take  care  of  themselves,  and  in  whom  nephritis  takes  from 
the  very  beginning  a  virulent  course.    Hofmeier  who  in  a  pre- 
vious calculation  saw  of  137  renally-diseased  pregnant  women 
33%   die  before  and  during  parturition   from  the  effects  of 
nephritis   (without  eclampsia),  admits  now  that  this  figure  is 
rather  too  high.     Among  the  better  classes  the  prognosis  is 
somewhat  more  favourable.     And  yet  it  is  not  good  enough 
to  enable  us  to  say  that  Fellner  is  wrong  when  he  asserts  that : 
"a  pregnancy  complicating  chronic  nephritis  leaves  behind  it 
far  more  serious  detriments  than  for  instance  in  the  case  of 
heart-disease. — The   prognosis   of   pregnancy   complicated   by 
chronic  nephritis  is  a  very  sad  one  for  mother  and  child,  a 
fact  which  has  not  hitherto  been  sufficiently  appreciated  by 
medical  practitioners  or  the  lay  public." 

As  regards  the  dangers  which  threaten  the  life  of  the  mother 
apart  from  the  increase  in  the  nephritic  process,  we  can  sum- 
marize them  briefly:  They  are  principally  premature  detach- 
ment of  the  placenta  with  atonic  haemorrhages,  and  eclampsia. 
The  latter  certainly  occurs  in  a  smaller  number  of  cases  than  in 
pregnancy-nephritis,  although  the  main  causation  recognised 
by  the  majority  of  authors,  namely  insufficient  activity  of  the 
kidneys  and  deficient  elimination  of  toxic  products  is  the  same 
in  both  processes.  This  is  not  the  place  to  enter  into  a  detailed 
description  of  the  theories  of  eclampsia,  but  the  reason  is  prob- 


462  HEALTH,  DISEASE,  MARRIAGE 

ably  that  in  chronic  nephritis,  as  we  shall  soon  see,  miscarriage 
occurs  very  frequently  and  at  a  very  early  stage,  and  that  with 
the  expulsion  of  the  foetus  a  source  of  toxaemia,  so  to  speak, 
to  the  maternal  organism  disappears. 

Prohibition  of  marriage  for  women  with 
chronic  nephritis. — What  are  the  conclusions  to  be 
drawn,  from  the  facts  narrated  above,  by  the  medical  practi- 
tioner who  is  asked  whether  females  with  chronic  nephritis 
should  be  allowed  to  marry  ?  There  can  be  no  doubt  from  what 
has  been  said  that  a  radical  prohibition  of  marriage  is  perfectly 
justified.  Where  the  persons  seeking  advice  on  the  point  think 
that  they  have  reason  to  disregard  it,  the  physician's  duty  is  to 
inform  their  relatives  as  to  the  dangers  of  the  marriage  and 
to  point  out  the  importance  of  averting  it,  if  possible. 

In  the  first  place  the  avoidance  of  pregnancy  by  the  employ- 
ment of  anti-conceptional  remedies — it  is  not  necessary  to  say 
here  anything  as  to  their  nature — is  to  be  recommended. 
Where  the  injurious  influence  of  pregnancy  is  eliminated,  we 
may  take  it  for  granted  that  chronic  nephritis  takes  no  other 
course  in  married  women  than  in  those  unmarried. 

Interruption  of  the  pregnancy  in  chronic 
nephritis. — Where  pregnancy  has  occurred,  the  physician 
will  have  to  consider  whether  and  for  how  long  he  must  try 
to  obtain  an  improvement  in  the  symptoms  by  the  usual  dietetic 
and  other  therapeutic  remedies  directed  against  nephritis,  and 
whether  it  is  possible  to  await  the  natural  end  of  the  pregnancy. 
On  this  point  almost  all  obstetricians  are  agreed — contrary  to 
what  has  been  said  above  in  respect  of  pregnancy-nephritis — 
that  active  interference  is  indicated,  especially  if  a  material 
aggravation  has  taken  place  from  the  commencement  of  the 
pregnancy  and  the  symptoms  have  rapidly  reached  a  dangerous 
degree.  Nature  herself  shows  us  the  way,  since  there  fre- 
quently ensues  after  the  death  of  the  foetus  and  its  spontaneous 
expulsion,  an  improvement  in  the  nephritis — according  to 
Fellner  a  sort  of  vis  medicatrix  natures,  and  at  the  same  time 
a  proof  how  injuriously  the  products  of  the  foetal  metabolism 
react  on  the  kidneys. 

With  regard  to  the  time  of  interference  it  is  not  possible 


DISEASES  OF   THE  KIDNEYS  463 

to  lay  down  any  definite  rules;  nor  does  the  alleviation  expected 
from  the  artificial  labour-act  always  set  in.  But  in  any  case 
it  is  to  be  presumed  that  the  longer  the  chronically  diseased 
kidney  of  the  pregnant  woman  is  subjected  to  the  sum  of 
injurious  influences  the  more  severe  and  the  less  reparable  the 
alterations  will  become.  The  decision  to  induce  artificial  abor- 
tion will  therefore  be  taken  as  early  as  possible,  if  the  albumi- 
nuria  becomes  more  pronounced,  if  the  organised  elements, 
namely  the  hitherto  scanty  casts  become  more  abundant,  if 
frequent  headaches,  gastric  and  intestinal  troubles  point  to  an 
increasing  insufficiency  of  the  renal  activity,  if  haemorrhages 
occur,  but  above  all  if  there  are  signs  of  disordered  cardiac 
action,  of  commencing  retinitis  albuminurica  or  of  eclamptic 
attacks.  Disturbances  in  the  cardiac  compensation  render  the 
artificial  determination  of  the  pregnancy  at  as  early  a  period 
as  possible  more  imperative  than  any  other  condition,  since  it 
is  but  natural  that  the  older  the  foetus  is  and  the  more  fully 
developed,  the  greater  the  demands  made  upon  the  action  of  the 
heart  during  the  labour-act.  Severe  collapse  with  a  fatal  issue 
has  repeatedly  been  observed  in  chronic  nephritis  during  and 
immediately  after  labour. 

The  decision  of  an  early  artificial  interruption  of  the  preg- 
nancy in  the  case  of  nephritis  of  the  mother  will  not  cause  any 
great  difficulties  to  the  medical  attendant,  the  more  so,  as  the 
chances  of  a  viable  child  being  born  are  comparatively  very 
slight. 

With  every  fresh  pregnancy,  as  we  pointed  out  more  cir- 
cumstantially above,  the  danger  to  the  mother  becomes  greater 
and  greater,  and  she  is  brought  "nearer  and  nearer  to  her 
grave."  For  this  reason  it  is  the  duty  of  the  physician  even 
where  a  first  pregnancy  has  been  successfully  tided  over,  con- 
trary to  his  expectation,  to  warn  most  energetically  against 
further  conception. 

Should  nephritic  mothers  suckle  their  children?  Whereas, 
according  to  Senator,  a  pregnancy-nephritis  which  has  been 
overcome  offers  no  centra-indication,  lactation  is  in  the  pres- 
ence of  chronic  nephritis  not  to  be  recommended,  because  it 
appears  to  act  unfavourably  upon  the  state  of  health  of  the 


464  HEALTH,  DISEASE,  MARRIAGE 

mother.  (See  Senator  "Die  Erkrankungen  der  Nieren,  2nd 
edit.  p.  248.) 

The  influence  of  the  nephritis  of  the  parents 
upon  the  offspring. — Let  us  consider  now  the  influence 
which  inflammatory  diseases  of  the  kidney  in  one  or  other  of 
the  parents  exert  upon  the  life  and  health  of  the  offspring. 
Here  also  the  illness  of  the  mother  is  by  far  of  greater 
importance. 

In  pregnancy-nephritis  the  consequences  are  practically  of 
no  moment.  Where  out  of  regard  for  the  welfare  of  the 
mother  a  premature  interruption  of  the  pregnancy  is  not  ren- 
dered necessary,  there  is  not  associated  with  the  disease  any 
injury  to  the  viability  of  the  embryo. 

It  is  however  different  in  the  case  of  chronic  nephritis. 
Here,  there  are,  quite  apart  from  the  requisite  medical  inter- 
ference, two  factors  which  are  disastrous  for  the  foetus:  In 
the  first  place  chronic  nephritis  in  a  pregnant  woman  causes 
not  infrequently  intra-uterine  death  of  the  foetus,  an  observa- 
tion for  which  we  are  indebted  to  Fehling.  The  causes  lie 
chiefly  in  a  deterioration  of  the  nutrition-material  which  reaches 
the  foetus,  as  the  maternal  blood  is  loaded  with  toxic  matter 
owing  to  the  insufficient  action  of  the  kidneys.  Then  there 
are  placental  changes  which  lead  to  an  obstruction  in  the 
placental  circulation  and  consequently  to  a  deficient  nutrition, 
a  sort  of  "slow  inanition"  of  the  foetus.  These  changes  con- 
sist according  to  Fehling  in  the  appearance  of  so-called  white 
infarcts,  in  disease  of  the  foetal  blood-vascular  connective-tissue 
apparatus,  in  destruction  of  numerous  placental  villi,  degen- 
eration of  the  chorion,  and  similar  other  such  occurrences. 
Secondly,  the  pregnancy  is  frequently  interrupted  spontaneously 
through  premature  labour.  According  to  figures  quoted  by 
Hofmeier  there  occurred  premature  labour  13  times  and  abor- 
tion 17  times  out  of  45  cases  of  chronic  nephritis.  Braun  saw 
as  many  as  89%  of  his  cases  end  in  premature  labour;  Fellner's 
statistics  relating  to  cases  from  Schauta's  clinic  show  50%  of 
premature  labour;  the  entire  mortality  of  the  children  amounted 
in  cases  without  eclampsia  to  34%;  others  give  much  higher 
figures. 


DISEASES  OF  THE  KIDNEYS  465 

But  whereas  the  dangers  of  chronic  nephritis  in  the  pro- 
creator  are  great  to  the  offspring,  while  the  latter  are  as  yet  in 
the  foetal  state,  they  are  only  insignificant  at  later  periods. 
Among  the  hereditary  diseases,  at  least  when  using  the  term 
in  its  popular  sense,  chronic  nephritis  is  not  included,  or  better 
said,  there  are  only  a  few  isolated  cases  in  which  a  sort  of 
extraordinary  "hereditary  albuminuria"  has  been  reported  as 
having  attacked  members  of  the  same  family  at  various  ages 
as  far  as  the  third  generation.  In  the  French  literature  men- 
tion has  recently  been  made  several  times  (Fournier,  Fieux 
and  others)  of  an  "hereditary  albuminuria"  and  nephritis  in 
newly-born  children  and  sucklings  whose  mothers  had  been 
eclamptic.  We  cannot  however  speak  here  of  an  heredity, 
seeing  that  these  are  cases  of  direct  toxic  action  on  the  part 
of  the  blood  of  the  eclamptic  mother  upon  the  foetal  kidneys. 
As  to  the  later  history  of  such  children  and  especially  whether 
these  albuminurias  pass  afterwards  into  chronic  nephritis  there 
is  no  sufficient  material  as  yet  collected.  All  these  observations 
are  so  far  more  of  interest  as  literary  curiosities  than  as  factors 
possessing  any  practical  importance. 

Summarising  at  the  termination  of  our  remarks  on  the 
relations  between  nephritis  and  marriage  the  principal  conclu- 
sions which  are  important  in  guiding  the  medical  practitioner 
to  arrive  at  a  decision,  they  may  be  said  to  be  as  follows :  The 
duration  of  life  of  candidates  for  marriage  suffering  from 
nephritis  is,  to  begin  with,  shorter  than  under  normal  circum- 
stances. This  applies  to  an  unequally  greater  extent  to  the 
female  sex  than  to  the  male  in  so  far  as,  with  regard  to  the 
former,  marriage  and  particularly  pregnancy  with  its  conse- 
quences supply  factors  which  are  capable  of  causing  consider- 
able injuries  to  the  kidneys,  which  almost  invariably  aggravate 
an  affection  already  existing  and  which  not  infrequently  are 
directly  dangerous  to  life. 

For  this  reason  the  decision  of  the  medical  practitioner  is 
of  far  greater  moment  to  the  wife  than  to  the  husband. 
Women  with  chronic  nephritis  ought  always  to  be  prohibited 
from  marrying.  But  where  they  do  marry  the  avoidance  of 
pregnancy  must  at  least  be  insisted  upon;  if  pregnancy  has 


466  HEALTH,  DISEASE,  MARRIAGE 

occurred  the  earliest  possible  interruption  of  the  same  is  indi- 
cated, in  case  the  symptoms  undergo  an  aggravation,  not  only 
on  account  of  the  life  of  the  mother  but  also  in  view  of  the 
improbability  that  the  embryo  will  be  born  alive.  Much  less 
dangerous  is  the  nephritis  of  pregnancy,  and  the  determination 
of  the  gestation  in  the  course  of  it  is  far  more  rarely  necessary 
owing  to  complications,  such  as  eclampsia,  retinitis,  etc.  More- 
over, contrary  to  what  takes  place  in  chronic  nephritis,  preg- 
nancy-nephritis does  not  become  more  dangerous  to  the  mother 
with  repeated  pregnancies,  but  rather  less  so.  A  transition  to 
chronic  nephritis  does  happen  but  is  not  of  frequent  occurrence. 

Amyloid  Disease  of  the  Kidney. 

The  amyloid  disease  of  the  kidneys  is  a  secondary  process 
which  may  be  due  to  curable  and  incurable  causes.  Where  the 
latter  is  the  case,  marriage  must  of  course  be  prohibited.  On 
the  other  hand  it  is  possible  that  with  the  disappearance  of  the 
cause  of  the  lardaceous  degeneration  the  process  in  the  kidneys 
may  come  to  a  standstill,  and  provided  the  disease  has  not  gone 
too  far  for  the  intact  portions  of  the  organs  to  maintain  the 
function  as  in  the  normal  state.  Thus  for  instance  anti-syphi- 
litic treatment  may  prove  successful  against  the  renal  affection 
as  well.  The  consent  to,  or  prohibition  of,  marriage  does  not 
however  depend  in  such  cases  upon  the  condition  of  the  kidneys 
but  entirely  upon  the  syphilis  in  general ;  for  further  details  the 
reader  is  referred  to  the  respective  chapter. 

Movable  Kidney. 

Movable  or  wandering  kidney  is  of  practical  importance 
in  the  female  only.  In  men  the  condition  has  been  observed 
in  an  insignificant  number  of  cases,  and  besides,  the  diagnosis 
is  not  always  certain.  We  will  therefore  consider  the  influence 
of  the  married  state  in  women  only. 

In  the  first  instance  we  must  examine  in  this  connection 
whether  pregnancy  and  parturition  supply  any  elements  favour- 
ing or  aggravating  the  complaint.  Opinion  on  the  subject 
varies.  Numerous  authors  see  in  the  relaxation  of  the  abdom- 


DISEASES  OF  THE  KIDNEYS  467 

inal  walls,  especially  after  repeated  pregnancies,  and  in  the 
muscular  over-exertion  during  labour,  as  well  as  in  the  insuffi- 
cient care  after  that  event,  an  important  factor  in  the  displace- 
ment of  the  kidney.  According  to  Senator,  Rollet,  and  others, 
the  predisposition  of  multipart  to  movable  kidney  is  greater 
than  in  other  women.  On  the  other  hand  Brault,  Matthieu, 
Knapp  and  others  have  noticed  also  in  multiparae  without  any 
flaccidity  of  the  abdominal  wall  a  considerable  percentage  of 
movable  kidney.  At  any  rate  the  influence  of  pregnancy  in 
this  respect  is  unmistakable.  It  cannot  be  denied  that  the 
symptoms  of  an  existing  movable  kidney  often  exacerbate  dur- 
ing pregnancy  and  more  so  after  the  confinement,  and  this 
becomes  apparent  principally  by  the  increase  in  the  pain.  That 
it  is  possible  owing  to  the  pressure  of  the  pregnant  uterus  for 
hydronephrosis  or  intermittent  hydronephrosis  to  develop  occa- 
sionally in  a  dislocated  kidney  has  been  proved  by  a  few 
reported  cases. 

On  the  other  hand  observations  have  been  recorded  where 
the  complaints  caused  by  movable  kidney  have  not  only  subsided 
during  pregnancy  but  where  the  dislocation  appeared  rectified 
after  parturition.  In  such  cases  marriage  exerts  therefore  a 
decidedly  healing  influence. 

In  any  case  floating  kidney  is  in  by  far  the  preponderating 
number  of  cases  so  harmless  a  complaint,  and  severe  compli- 
cations in  the  married  state  are  so  rare  that  it  does  not  present 
any  reasonable  ground  for  prohibiting  a  marriage. 

Pyelitis,  Pyelonephritis  and  Pyonephrosis. 

We  will  consider  these  diseases  together  since  they  only 
represent  different  degrees  of  one  and  the  same  process. 

The  relations  which  they  bear  to  the  married  state  are  also 
far  more  prominent  in  the  female  sex.  In  man  marriage  does 
not  present  any  special  factors  which  influence  the  course  of 
these  diseases.  In  so  far  as  the  pyelitis  is  of  gonorrhoeal  origin 
the  consent  to  the  contraction  of  a  marriage  will  depend  upon 
the  remaining  manifestations  of  the  gonorrhoeal  infection  and 
it  will  therefore  be  treated  in  the  chapter  dealing  with  the 
latter  disease. 


468  HEALTH,  DISEASE,  MARRIAGE 

In  any  case  the  physician  whose  advice  is  sought  on  the 
point  will  have  to  remember  that  chronic  pyelitis  and  pyelone- 
phritis is  a  long-lasting  disease  which  generally  resists  all 
internal  medication  and  is  no  less  difficult  to  treat  locally,  that 
perfect  cures  are  not  often  achieved,  but  that  on  the  contrary 
very  severe  complications  may  sometimes  arise  through  conges- 
tion of  urine  and  retention  of  pus.  The  duty  of  the  medical 
adviser  is  therefore  to  point  out  to  candidates  for  marriage 
that  pyelitis  is  not  exactly  so  harmless  a  complaint  as  it  is  yet 
generally  thought  to  be. 

In  the  wife,  marriage  is  capable  of  giving  rise  to  pyelitic 
processes,  or  it  may  considerably  aggravate  those  already  exist- 
ing to  such  an  extent  as  to  even  endanger  life.  We  do  not 
speak  here  of  the  transmission  of  gonorrhoea  by  means  of  the 
sexual  intercourse,  an  infection  which  is  just  as  often  the  cause 
of  purulent  inflammations  of  the  pelvis  of  the  kidney  in  women 
as  it  is  in  men.  It  is  rather  pregnancy  which  we  are  thinking 
of  and  which  offers  a  most  favourable  soil  for  the  formation 
and  progress  of  pyelitis. 

The  causes  lie  first  of  all  in  the  congestion  which  takes 
place  during  pregnancy  in  the  pelvic  and  abdominal  organs. 
The  bladder  is  affected  in  the  first  instance  and  as  long  as  the 
process  may  advance  from  there  upwards  as  far  as  the  pelvis 
of  the  kidney,  the  latter  is  therefore  indirectly  also  subject  to 
be  attacked.  But  the  kidneys  themselves  also  become  congested 
with  blood  and  offer  therefore  to  the  microbes  coming  from  the 
neighbourhood  into  the  pelvis  of  the  kidney  by  means  of  the 
circulation  a  suitable  medium  of  propagation.  Secondly, 
mechanical  conditions  also  come  into  play;  overcrowding  in  the 
pelvis  on  account  of  the  pregnant  uterus,  and  still  more,  a  stran- 
gulation of  the  ureter  leading  to  an  obstruction  in  the  passage 
of  the  urine,  thus  causing  in  its  turn  further  venous  congestion 
and  thereby  facilitating  the  settlement  of  infective  existing 
agents  in  the  pelvis  of  the  kidney. 

What  influence  does  pyelitis  exercise  upon  the  course  of 
pregnancy?  The  latter  may  in  spite  of  grave  symptoms  reach 
its  natural  end. 

Fellner  reports  two  such  cases :  they  both  refer  to  the 


DISEASES  OF  THE  KIDNEYS  469 

same  pregnant  woman,  during  her  first  and  second  preg- 
nancies. In  the  first  pregnancy  the  symptoms  were  at 
the  beginning  rather  slight ;  but  at  the  6th  month  a  con- 
siderable aggravation  took  place.  There  was  a  discharge 
of  pus  from  the  right  ureter,  as  proved  by  cystoscopic 
examination.  Neither  general  nor  local  treatment  ap- 
peared to  have  any  effect,  so  premature  labour  was 
decided  upon.  The  patient  however  would  not  agree 
to  this,  and  gave  birth  afterwards  to  a  living  mature 
child.  The  same  process  repeated  itself  in  the  second 
pregnancy. 

A  similar  favourable  result  was  also  recorded  in  the  cases 
of  V'may.  For  this  reason,  this  author  is  opposed  to  the  arti- 
ficial interruption  of  the  pregnancy  even  in  severe  cases.  Others, 
like  Depage,  Fellner,  etc.,  try  at  first  to  remove  the  complaint 
by  suitable  treatment,  but  are  in  favour  of  premature  labour 
being  instituted  where  there  is  protracted  elevation  of  tempera- 
ture and  an  unsatisfactory  general  condition,  the  more  so  as 
with  the  occurrence  of  the  abortion  and  the  disappearance  of 
the  pressure  and  the  congestion,  the  pyelitis  also  disappears  as 
a  rule. 

Sometimes  pregnancy  may  give  rise  to  an  aggravation  of 
simple  pyelitis  to  the  extent  of  severe  pyonephrosis.  Such  a 
case  is  communicated  by  Israel: 

The  patient  in  question  miscarried  in  her  first  preg- 
nancy.    In  association  with  this,  cystitis;  3  years  after- 
wards, renewed  pregnancy.     In  the  course  of  the  latter 
there  were  as  yet  no  renal  complaints,  but  during  the 
puerperium,  pain  in  the  left  side  and  fever.     The  dis- 
turbances subside  until  the  next  pregnancy  and  puer- 
perium,  which,   particularly  the  latter,   cause  such   an 
acute  exacerbation  of  the  symptoms  that  nephrotomy 
becomes   necessary.      In  the   third   pregnancy,   violent 
pains  in  the  abdomen.     Growth  of  a  pyonephrotic  sac, 
to  the  size  of  a  child's  head.    Later,  nephrectomy. 
Pyelitis  is  therefore  in  women  also  by  no  means  a  harmless 
affection,  and  women  with  pyelitic  symptoms  should  in  any  case 
undergo  a  thorough  treatment  before  being  allowed  to  marry. 


470  HEALTH,  DISEASE,  MARRIAGE 

According  to  some  authors  (Depage,  and  others)  the  pyelitis 
of  pregnant  women  is  altogether  not  a  process  which  commences 
during  pregnancy,  but  a  recrudescence  of  old  inflammatory 
remains,  such  as  is  caused  especially  by  the  upward  extension 
of  cystitis  which  is  so  frequent  in  women. 

Tuberculosis  of  the  Kidneys. 

In  the  consideration  of  the  influence  of  the  married  state 
upon  the  tuberculosis  of  the  kidneys  and  of  the  question  of  the 
consent  to  marriage  in  such  cases,  we  can  here  take  notice  of 
those  forms  of  the  disease  only,  in  which  the  tuberculosis  has 
attacked  the  kidneys  exclusively,  or  at  least  where  the  renal 
symptoms  occupy  the  foremost  place  in  the  clinical  picture. 
Where  the  disease  of  the  kidneys  forms  a  part-symptom  of  a 
general  tuberculosis,  and  especially  where  it  is  present  in  combi- 
nation with  pulmonary  tuberculosis,  the  latter  is  the  factor 
which  will  influence  the  decision  of  the  medical  adviser.  And 
also  where  it  is  a  case  of  the  so-called  ascending  form,  that  is, 
the  form  which  takes  its  origin  from  a  tuberculosis  of  the  blad- 
der or  of  the  generative  organs,  the  primary  cause  must  neces- 
sarily be  the  decisive  element,  if  only  on  account  of  the  risk  of 
infection  by  means  of  sexual  intercourse. 

We  will  therefore  discuss  in  this  article  only  cases  of  descend- 
ing or  so-called  primary  tuberculosis  of  the  kidneys  which  is 
bound  to  affect  in  its  later  course  also  other  parts  of  the  urinary 
apparatus.  The  practical  interest  of  this  form  lies  principally 
in  the  fact  that  it  is  not  at  all,  as  was  previously  believed,  of 
rare  occurrence;  but  that  it  is,  on  the  contrary,  as  Israel  espe- 
cially has  pointed  out,  a  comparatively  frequent  disease  of  the 
kidneys. 

As  regards  the  consequences  of  marriage  to  the  husband 
suffering  from  renal  tuberculosis,  they  are  practically  covered 
by  those  of  sexual  intercourse  altogether,  which  is  sure  to  favour 
a  rapid  extension  of  the  tuberculous  process.  The  abstention 
from  sexual  connection  in  tuberculosis  of  the  kidney  appears 
therefore  to  be  indicated. 

In  the  wife  there  are  to  be  added  to  the  injurious  effects  of 


DISEASES  OF   THE  KIDNEYS  471 

sexual  intercourse  those  of  its  results,  namely  pregnancy  and 
parturition,  and  to  an  even  greater  extent  than  it  has  been 
repeatedly  explained  with  respect  to  other  diseases  of  the  kidney. 
Israel  observes  truly:  "If  the  unfavourable  influence  of  preg- 
nancy affects  all  renal  complaints,  it  does  so,  above  all,  tuber- 
culosis." We  not  infrequently  see  that  for  years  the  malady 
produces  no  symptoms  at  all,  or,  at  the  utmost,  only  such  as 
would  result  from  a  slight  cystitis  with  inconsiderable  urinary 
disturbances,  a  somewhat  increased  desire  for  micturition,  or 
similar  inconveniences,  so  that  nothing  lies  further  than  the 
thought  of  a  renal  affection,  and  especially  tuberculosis.  It 
is  only  during  pregnancy  that  a  rapid  aggravation  of  the  symp- 
toms takes  place,  which  guides  to  a  correct  diagnosis.  This 
is  clearly  demonstrated  by  a  case  described  by  Israel.  ( Chirurg. 
Klinik  der  Nierenkr.,  p.  220.) 

Mrs.  G.,  20  years  old,  has  with  the  exception  of  a 
somewhat  frequent  micturition  and  a  paroxysmally  oc- 
curring pain  in  the  region  of  the  left  kidney,  which 
however  disappeared  very  quickly,  never  suffered  from 
any  illness  of  the  urinary  organs.  She  married  without 
knowing  that  she  was  subject  to  any  disease.  In  the 
first  months  of  pregnancy  rapid  decline,  under  forma- 
tion of  an  enormous  renal  tumour.  In  the  purulent 
renal  secretion  tubercle  bacilli  were  demonstrated.  The 
left  kidney  is  removed,  and  is  seen  to  have  changed  into 
a  system  of  large  pus-containing  sacs  separated  by 
thin  partition-walls.  The  pregnancy  goes  on  after  the 
nephrectomy  without  any  disturbance.  The  patient  is 
confined  of  a  healthy  child,  and  has  since  undergone  sev- 
eral pregnancies  without  any  injury. 

It  is  possible  even  for  several  pregnancies  to  pass  without 
any  symptoms  until  the  last  one  occasions  a  considerable  aggra- 
vation of  the  disease  which  had  hitherto  hardly  been  noticeable, 
or  at  any  rate  unknown  to  the  patient  and  her  friends.  A 
remarkable  instance  of  this  sort  is  also  contained  in  Israel's 
casuistic  communications : 

In  a  patient  who  has  already  gone  through  two 
normal  confinements  and  in  whose  history  there  is  noth- 


472  HEALTH,  DISEASE,  MARRIAGE 

ing  of  consequence  to  be  mentioned  except  a  pleurisy 
from  which  she  suffered  at  an  early  age,  and  occasional 
bronchial  catarrhs,  who  had  further  never  complained  of 
any  troubles  in  connection  with  the  urinary  organs,  except 
an  increased  desire  for  micturition,  there  came  on  in 
the  first  month  of  pregnancy  violent  renal  colic.  The 
right  kidney  swelled  up  rapidly  and  considerably,  the 
right  ureter  was  distinctly  to  be  felt  thickened.  After 
the  induction  of  abortion  the  condition  improved,  the 
attacks  of  colic  appeared  at  long  intervals,  the  swelling 
disappeared.  The  tuberculous  nature  of  the  disease 
being  afterwards  established  with  certainty,  the  kidney 
was  extirpated. 

Finally  it  is  possible  under  the  influence  of  pregnancy  for 
an  operated  and  healed-up  tuberculosis  of  the  kidney  to  break 
out  afresh.    Israel  communicates  the  following  pertinent  case: 
In  a  woman  with  renal  tuberculosis  the  amputation 
of  the  upper  third  of  the  left  kidney  is  performed.  After 
the  operation  the  urine  becomes  perfectly  clear,   the 
patient  goes  through  a  pregnancy  and  labour  without 
injury  to  her  general  health.     In  the  second  pregnancy 
miscarriage  occurs  in  the  second  month,  and  is  succeeded 
by  marked  lassitude,   fever  and  frequent  micturition. 
The  urine  contains  pus  and  some  albumen.     Tubercle 
bacilli  are  not  found.     Nephrectomy  reveals  a  tuber- 
culous kidney. 

Much  more  deleterious  are  the  consequences  of  pregnancy 
if  the  tuberculosis  not  only  attacks  one  kidney,  but  if  after  the 
operation  of  nephrectomy  the  remaining  organ  is  also  found 
not  to  be  perfectly  intact.  A  case  communicated  by  Konig 
illustrates  this  condition  better  than  any  amount  of  theoretical 
explanation : 

The  left  kidney  of  a  ly-year-old  girl  is  removed  on 
account  of  tuberculosis.  Despite  the  proof  that  the 
right  kidney  is  also  affected  the  patient  gains  in  weight, 
feels  perfectly  well  and  enjoys  life  so  much  that  she 
is  constantly  and  for  years  worrying  the  operating  sur- 
geon to  allow  her  to  get  married.  He  refuses  to  do  so. 


DISEASES  OF  THE  KIDNEYS  473 

The  patient  marries  contrary  to  advice,  becomes  preg- 
nant, develops  haematuria  and  dies  in  the  puerperium. 

To  avert  these  dangerous  consequences  if  pregnancy  has 
supervened,  two  remedies  come  into  consideration :  artificial 
premature  abortion  and  nephrectomy.  If  practicable,  and 
above  all,  if  the  condition  of  the  second  kidney  offers  no  contra- 
indication, the  latter  course  is  to  be  preferred.  The  abortion, 
it  is  true,  removes  the  danger  for  the  moment,  but  it  is  naturally 
not.  to  be  expected  that  it  will  act  as  a  permanent  cure  of  the 
tuberculous  process,  whereas  such  a  result  is  possible  after 
nephrectomy.  That  notwithstanding  nephrectomy  a  pregnancy 
can  continue  to  its  natural  conclusion  and  that  also  subsequent 
pregnancies  and  labours  may  run  a  favourable  course  is  proved 
by  the  above-quoted  cases. 

What  are  we  to  conclude  now  from  these  facts  with  respect 
to  the  consent  to  marriage?  It  is  only  those  cases  that  can 
come  here  into  question,  where  a  successful  treatment,  either 
medicinal  or  surgical,  has  been  instituted,  cases  which  conse- 
quently do  no  longer  exhibit  any  symptoms;  for,  that  cases 
with  manifest  renal  tuberculosis  necessitate  an  absolute  prohi- 
bition of  marriage,  follows  as  a  matter  of  course,  apart  from 
other  reasons,  from  the  aggravation  which  sexual  inter- 
course occasions  to  begin  with.  The  difficulty  for  the  physician 
lies  chiefly  in  the  circumstance  that  but  in  rare  cases  the  diagnosis 
of  commencing  tuberculosis  of  the  kidneys  can  be  readily  made. 
There  is  hardly  another  disease  of  the  urinary  organs  which  in 
its  early  stages  is  so  often  mistaken  as  this  one.  If  with  the 
exception  of  a  slight  increase  in  the  frequency  of  micturition 
there  is  nothing  to  point  to  an  affection  of  the  uropoetic  system, 
if  the  urine  is  perfectly  normal  or  if  it  shows  at  the  outside 
insignificant  cystitic  changes,  such  as  are  frequently  observed 
in  the  female  sex  without  any  special  reason,  if  the  patients 
present  at  the  same  time  for  years  the  picture  of  perfect  health, 
it  is  not  surprising  that  tuberculosis  is  little  thought  of,  and 
especially  tuberculosis  of  the  kidneys.  Nevertheless  it  must 
again  be  emphasised  that  the  disease  is  by  no  means  rare  and 
that  it  deserves  the  attention  of  the  general  practitioner. 

In  the  cases  which  have  undergone  treatment,  particularly 


474  HEALTH,  DISEASE,  MARRIAGE 

in  those  where  by  the  extirpation  of  the  kidney  the  tuberculous 
focus  has  been  eliminated,  where  there  has  consequently  been 
as  yet  no  spreading  of  the  disease  along  the  ureters  into  the 
bladder,  as  may  be  proved  among  other  means  by  cystoscopic 
examination,  and  where  the  persons  concerned  have  for  some 
time  since  the  operation  enjoyed  perfect  health,  an  absolute 
prohibition  of  marriage  is  probably  not  quite  justified.  Here 
at  least  there  need  not  be  any  injurious  influence  exercised  on 
the  part  of  the  marriage ;  for  we  have  seen  in  some  of  the  cases 
mentioned  above  that  after  nephrectomy  repeated  pregnancies 
have  been  well  endured  and  that  they  resulted  in  the  birth  of 
viable  children.  The  definite  decision  of  the  medical  adviser 
will  not  depend  so  much  either  on  the  previous  history  of  the 
disease,  that  is,  the  tuberculosis,  but  it  is  rather  the  circumstance 
generally  whether  and  when  marriage  is  permissible  after  the 
sacrifice  of  so  vital  an  organ  as  the  kidney,  that  will  constitute 
a  weighty  argument  in  the  consideration.  This  question  will 
yet  engage  our  attention  in  another  place. 

Renal  Calculi  and  Renal  Tumours. 

We  can  deal  with  these  affections  in  a  very  few  words. 
Marriage  exercises  hardly  any  influence  upon  the  course  of 
nephrolithiasis  unless  it  is  upon  the  pyelitis  caused  by  it.  (See 
under  pyelitis.)  But  the  physician  consulted  with  regard  to 
the  contraction  of  marriage  will  have  to  bear  in  mind  that 
renal  calculus  is  an  affection  whose  duration  and  course  cannot 
be  determined  beforehand,  that  free  intervals  extending  over 
long  periods  happen  in  its  course,  but  that  the  life  of  the  patient 
may  be  endangered  by  acute  complications  and  that,  even  with- 
out these,  the  consequences  to  the  renal  activity  and  to  the  entire 
organism  may  become  very  serious.  At  any  rate  the  life-dura- 
tion of  individuals  with  renal  calculi  must  be  regarded  as 
shorter  than  that  of  normal  persons. 

It  appears  moreover  that  the  offspring  of  such  individuals 
are  also  in  peril  inasmuch  as  heredity  plays  here  undoubtedly 
a  part,  though,  with  respect  to  calculi,  not  to  such  an  extent 
as  was  formerly  believed.  It  certainly  more  rarely  happens 
that  nephrolithiasis  as  such  is  inherited  than  that  allied  con- 


DISEASES  OF  THE  KIDNEYS  475 

stitutional  anomalies  especially  gout  and  diabetes  are  met  with 
in  the  respective  families. 

Be  that  as  it  may,  the  physician  will  have  to  point  out  to 
the  descendants  of  families  so  predisposed  the  risk  which  they 
are  running,  and  to  endeavour  to  prevent  the  disease,  especially 
if  such  districts  come  into  play  in  which  lithiasis  is  endemic, 
and  if  there  are  also  other  unknown  factors  concerned  in  the 
matter,  such  as  climate,  the  constitution  of  the  soil,  drinking- 
water  (  ?) ,  etc.  Since  we  are  at  present  powerless  in  the  face  of 
these  factors  about  which  we  know  so  little,  it  will  often  be 
necessary  to  recommend  a  removal  into  some  other  locality. 

It  is  scarcely  necessary  to  mention  that  no  cautious  medical 
man  will  ever  think  of  consenting  to  the  marriage  of  persons 
with  renal  tumours. 

Renal  Operations  especially  Nephrectomy. 
The  great  success  which  renal  surgery  has  achieved  in 
recent  times  makes  it  of  practical  interest  to  consider  the  ques- 
tion whether  and  how  far  it  is  justifiable  to  prohibit  the  mar- 
riage of  individuals  who  possess  only  one  kidney.  This  point 
has  as  far  as  we  know  been  raised  for  the  first  time  by  Schramm 
in  connection  with  a  case  which  he  reported  in  the  Berliner 
Klinische  Wochenschrift  in  1896. 

It  concerned  a  patient  who,  having  undergone 
nephrectomy  in  1891  on  account  of  hydronephrosis, 
married  3  years  later  and  became  pregnant  soon  after- 
wards. During  the  pregnancy  the  excretion  of  urine 
increased  to  a  marked  degree;  the  urine  was  of  low 
specific  gravity  and  contained  albumen,  so  that  it  was 
at  first  thought  to  be  a  case  of  chronic  nephritis.  Later 
on  Schramm  considered  that  a  congestive  albuminuria 
was  a  more  probable  cause;  the  labour  passed  off  nor- 
mally and  the  albuminuria  disappeared  rapidly  soon 
afterwards. 

On  the  strength  of  this  observation  Schramm  goes  into 
the  subject  which  interests  us  here,  namely  on  the  attitude  of 
the  physician  in  the  presence  of  a  woman  with  one  kidney  who 
wishes  to  marry,  and  whether,  if  she  is  already  married,  she 


476  HEALTH,  DISEASE,  MARRIAGE 

has  to  apprehend  any  serious  dangers  from  eventual  preg- 
nancies. In  spite  of  the  favourable  issue  in  his  case  he  takes  up 
a  rather  reserved  position;  he  arrives  at  the  result  that  such 
"patients"  should  be  prohibited  from  contracting  marriage  or 
at  least  from  cohabitation,  because  they  expose  themselves  dur- 
ing pregnancy  to  the  risk  of  a  pregnancy-nephritis  or  chronic 
nephritis,  against  which,  having  only  one  kidney,  they  will 
naturally  be  able  to  offer  but  a  diminished  resistance. 

To-day  when  the  casuistic  literature  is  more  extensive  than 
it  was  at  that  time,  it  is  open  to  argument  whether  this  abso- 
lutely pessimistic  view  is  justified  at  all.  The  points  of  view 
which  should  guide  the  physician  in  his  attitude  that  need  not 
necessarily  be  a  negative  one  are  in  our  opinion  as  follows: 

1.  It  is  necessary  that  the  nephrectomy  be  dictated  by  a 
cause  which  has  at  least  in  all  probability  been  removed  with 
the  removal  of  the  kidney.     But  if  the  operation  was  indicated 
by  the  presence  of  a  malignant  tumour   (carcinoma,  sarcoma, 
struma  renalis,  etc.)  the  risk  of  relapse  justifies  a  prohibition 
of  the  marriage.     So  far,  at  any  rate,  the  distant  results  of 
operation  in  such  cases  even  if  it  is  performed  at  the  earliest 
stage,  are  not  good  enough,  to  warrant  the  assumption  of  a 
longer  duration  of  life. 

2.  Where  the  original  illness  is  in  itself  no  obstacle  against 
marriage,  the  remaining  kidney  must  with  certainty  be  known 
to  be  anatomically  and  functionally  sound;  otherwise  there  is, 
particularly  in  pregnancy,  great  danger.     I  have  already  men- 
tioned the  case  of  Konig  where  a  person  with  a  diseased  second 
kidney  lived  apparently  in  good  health  until  she  married ;  during 
her  pregnancy  disturbances  on  the  part  of  the  renal  activity  made 
their  appearances,  and  the  woman  died  in  the  puerperium.    The 
case   illustrates   the   oft-repeated   experience    that    a    diseased 
kidney  is  capable  for  some  time  of  fulfilling  the  demands  made 
upon  its  function  by  the  organism,  but  that  it  becomes  unequal 
to  it  as  soon  as  these  demands  increase  for  any  reason  to  too 
great  an  extent.     The  fears  entertained  by  Schramm  that  the 
remaining  sound  organ  will  also  be  affected  by  the  more  difficult 
circulatory   conditions   established   during   pregnancy,   by   the 
increased  secretory  activity,  especially  in  so  far  as  the  toxic 


DISEASES  OF  THE  KIDNEYS  477 

substances  formed  by  the  maternal  and  foetal  organisms  are 
concerned  and  by  similar  other  agencies,  are  certainly  justified 
and  noteworthy,  at  least  theoretically.  Nevertheless  experience, 
which  is  after  all  our  best  teacher  in  spite  of  all  theoretical 
assumptions,  shows  us  that  these  apprehensions  need  not  by  any 
means  always  be  realised  in  practice.  Thus  Tredondani  reports, 
though  more  as  a  Curiosity,  the  case  of  a  woman  in  whom 
nephrectomy  was  performed,  and  who  gave  birth  afterwards 
to  3  healthy  children;  and  he  reproves  those  earlier  authors 
who  desired  to  ascribe  to  the  operation  an  injurious  influence 
upon  pregnancy.  And  from  Israel's  rich  experience  we  have  in 
previous  passages  also  quoted  several  cases  in  which  pregnancy 
ran  a  normal  course  in  spite  of  previous  nephrectomy. 

In  man  the  conditions  are  naturally  far  more  favourable 
than  in  woman.  Really  speaking,  there  are  no  factors  in  his 
case  which  can  occasion  an  injurious  influence  upon  the  married 
state,  provided  the  above  precautions  are  duly  taken. 

How  very  little  agreement  there  is  between  a  too 
rigorous  interpretation  of  the  condition  of  affairs  and 
the  actual  facts,  was  shown  to  me  by  a  case  of  my  own 
observation,  in  which  a  man  who  had  had  one  of  his  kid- 
neys removed  on  account  of  pyonephrosis  was  strongly 
advised  by  a  high  medical  authority  not  to  get  married; 
an  engagement  into  which  he  had  already  entered  was 
consequently  broken  off.  The  gentleman  in  question 
did  not  however  adhere  to  the  medical  advice  for  good ; 
he  married  subsequently  and  is  now  after  8  years  of 
married  life  the  father  of  3  healthy  children;  he  is  in 
splendid  health. 


INDEX 


(Words  in  brackets  following  a  name  denote  the  subject  dealt  with  by  that  Author.) 


Abnormal  position  in  sexual  inter- 
course, 213,  226. 

Abortion,  artificial  in  asthma,  401. 

Abortion  in  America,  204. 

Abortion,  premeditated  anthropol.  ob- 
serv.  on,  203. 

Abortion,  prophylactic  in  tuberculosis, 

392. 

Abortion,  therapeutic,  255. 

Abstention,  sexual.  See  Sexual  ab- 
stention. 

Abstinence,  diseases  of,  228,  229. 

Acclimatation,  128. 

Acclimatement,  128. 

Acclimatisation,  127. 

Acclimatisation  in  tropics,  136. 

Acclimatisation,  gradual,  164. 

Acclimatisation  of  races,  145. 

Acclimatisation  of  females,  141. 

Acclimatisation,  possibility  of,  163. 

Acclimatisation,  predisposition  for, 
141. 

Acquired,  the  opposite  of  inherited,  37. 

Acquired,  what  is,  41. 

Acquired  peculiarities,  hereditary 
transmission  of,  58. 

Acromegaly  and  marriage,  288. 

Acton  (frequency  of  sex.  interc.),  221. 

Acute  yellow  atrophy  of  liver,  430. 

Adam  and  Eve,  83. 

Addison's  disease,  289. 

Adenia,  leukaemic.  359. 

Adipositas.      See  Obesity. 

Adipositas  dolorosa,  286. 

Adler  (sex.  anaesthesia  in  woman),  217. 

Adler  (titillativ  chlorides),  240. 

Adnexa,  changes  in,  426. 

Adultery,  231. 

Age,  marriageable,  173. 


Age  of  parents,  effects  of,  on  offspring, 

27- 

Agres  (statistics  on  consang.  marr.), 
101. 

Albert  (case  of  laceration  of  vagina), 
215. 

Albuminuria  of  puberty,  446. 

Albuminuria,  physiological,  444. 

Alcohol  and  heart  disease,  347. 

Alcohol  in  the  tropics,  144. 

Alcoholism  of  parents,  effects  of,  on 
offspring,  29. 

Alphonse  of  Liguori  (intercourse  dur- 
ing child-bed),  260. 

Alphonse  of  Liguori  (menstruation), 
248. 

America,  abortion  in,  204. 

American  women  and  motherhood,  201. 

Ammann  (haemophilia),  313. 

Ammon.     See  Reibmayer. 

Ampallangs,  240. 

Amphimixis,  cause  of  germ-variation, 
61. 

Anyloid  disease  of  the  kidney,  466. 

Anaemia,  298. 

Anaemics  and  marriage,  303. 

Anaemics  and  their  offspring,  305. 

Anaesthesia  sexualis  feminarum,  217. 

Anaphrodisia,  217. 

Andral  (tuberculosis  and  pregnancy), 
372. 

Aneurysia,  356. 

Angina  pectoris,  353. 

Angina  pectoris  neurasthenica  vaso- 
motoria,  354. 

Anomalies  and  malformations,  heredi- 
tary transmission  of,  52. 

Anthropological  observations  on  mar- 
riage, 192. 

Anti-conceptional  measures.  See  pre- 
ventive intercourse. 


480 


INDEX 


Anti-conceptional  remedies,  254. 
Antiseptic  introductions  for  preventing 

conception,  237. 
Aorta,  stenosis  of,  326. 
Aphthous,  stomatitis,  415. 
Apoplexy  and  sexual  intercourse,  218. 
Appendicitis,  423. 
Appendicitis  larvata,  426. 
Appetitus  cceundi,  221. 
Aristotle  (marriage),  6. 
Arrago  (Goam),  96. 
Arteries,  diseases  of,  351. 
Arterio-sclerosis,  218. 
Arterio-sclerosis,  351. 
Arterio-sclerosis  and  conception,  355. 
Arterio-sclerosis  and  pregnancy,  356. 
Arthritis  urica,  279. 
Ashton  (haematemesis),  418. 
Assmuth  (continence),  228. 
Asthma  and  lactation,  401. 
Asthma  and  marriage,  399. 
Asthma  and  pregnancy,  400. 
Asthma  and  sexual  intercourse,  400. 
Asthma,  artificial  abortion  in,  401. 
Asthma,  bronchial,  398. 
Atavism,  30,  74. 
Athenians,     marr.    of   blood-relations 

among,  95. 

Audibert  (ptyalism  in  pregnancy),  413. 
Australasians,  185. 

B 

Bacon,  quoted,  37. 

Bacteriorrhoea,  225. 

Baelz  (infant,  mortal.),  178. 

Bagnold  (Indian  climate),  131. 

Bailey  (consang.  marr.),  99. 

Bauti's  disease,  316. 

Bardeleben  (premature  labour),  343. 

Barruco  (sexual  neurasthenia),  235. 

Barruco  (condoms),  239. 

Barruco  (interrupted  coitus),  236. 

Bartels  (nephritis),  450. 

Bastian  (marriage-forms),  179. 

Bastian  (acclimatisation,  etc.),  146. 

Baumes  (tuberculosis  and  pregnancy), 
372. 

Beard  (interrupted  coitus),  235. 

Beard  (condoms),  239. 

Beard  and  Rockwell  (sexual  neuras- 
thenia), 221. 

Beauty  of  female  sex,  180. 

Bebel  (continence),  229. 

Beck  (tuberculosis),  366. 

Bergerel  (interrupted  coitus),  236. 

Berkart  (asthma),  398. 

Bertillon  (acclimatisation,  etc.),  147, 
148. 

Bertz  (cycling),  242. 

Binswanger  (neurasthenia),  223. 

Birch-Hirschfeld  (haemophilia),  311. 

Birch-Hirschfeld  (tubercle  bacillus), 
379- 


Birmer  (pernicious  anaemia),  316. 

Blessig  (continence),  228. 

Blood,  changes  in  the,  during  preg- 
nancy, 333. 

Blood,  diseases  of  the,  in  relation  to 
marriage,  295. 

Blood-relations,  marriage  of,  62. 

Blood-relations,  marriage  between ; 
laws  and  customs,  etc.,  86,  etc. 

Blood-relationship,  degrees  of,  82. 

Blood,  historical  and  ethnographical 
remarks,  89. 

Blood,  transmission  of  disease  through 
the,  40. 

Blood  relationship.  See  also  Consan- 
guinity. 

Blot  (heart  disease  and  pregnancy), 
330. 

Blowers,  402. 

Bockhart  (bacteriorrhcea),  225. 

Boeckh  (statistics,  mortality),  24. 

Boers,  152. 

Bordeau  (tuberculosis  and  pregnancy), 
372. 

Bossi  (malaria),  430. 

Bossi's  method  of  premature  labour, 
343- 

Bonardi  (acromegaly),  289. 

Bouchard  (diabetes),  276. 

Bouchard  (gout),  280. 

Bouchard  (obesity),  283. 

Boudin  (consang.  marr.),  97,  99,  101. 

Bourgeois  (consang.  marr.),  99. 

Boye  (appendicitis),  423. 

Brauer  (haemoglobinuria),  430. 

Brault  (movable  kidney),  467. 

Braun  (gout),  280. 

Braun  (heart  disease),  353. 

Braun  (nephritis),  464. 

Breasts,  female,  anthropological  and 
physiological  observations  on,  196. 

Breuer  and  Freud  (sexual  trauma),  216. 

Breymann  (acromegaly),  289. 

Brierre  de  Boismont  (menstr.),  170. 

Brocard  (diabetes),  267. 

Bronchiectasis  (foetus),  404. 

Bronchial  asthma,  398. 

Bronchitis,  chronic,  403. 

Bronchitis,  fibrinous,  403. 

Bronchitis,  foetid,  404. 

Bronchitis,  plastic,  403. 

Bronchicele,  346. 

Brown  Seguard's  experiments  on  arti- 
ficial epilepsy.  68. 

Bruggemann  (asthma),  399. 

Buchner  (consang.  marr.),  96. 


Calculi,  renal,  474. 
Cameron  (leukaemia),  317. 
Cameron  (Wangoro),  96. 
Cancer  in  husband  and  wife,  410. 
Carpentier  (nephritis),  458. 


INDEX 


481 


Casper  (bacteriorrhoea),  225. 

Casper  (continence),  229. 

Catheterpurin,  237. 

Catholic  Church  and  intercourse  dur- 
ing child-bed,  260. 

Catholic  Church  on  subject  of  men- 
struation, 248. 

Celibacy,  193. 

Cells,  germinal.     See  Germinal   cells. 

Chamberlain  (Slavs),  93. 

Chambers  (obesity),  283. 

Charcot  (Grave's  disease),  347. 

Charpentier  (acute  yellow  atrophy),432. 

Chelius  (haemophilia),  314. 

Chemical  changes,  hereditary  trans- 
mission of,  70. 

Child-bed  and  marriage,  257. 

Child-bed,  etc.,  in  relation  to  marriage, 

245- 

Child-bed,  sexual  intercourse  during, 
260. 

Chinos,  184. 

Chloasma  uterinum,  252. 

Chloroform  in  labour,  332. 

Chlorosis,  306. 

Chlorosis  and  heart  disease,  326. 

Chlorosis  and  marriage,  22. 

Chlorotics  and  marriage,  308. 

Choice  of  husband  and  wife,  31. 

Cholaemia,  432. 

Cholera,  160. 

Cholos,  184. 

Christianity,  influence  of,  on  marriage, 
7,  10. 

Christians  and  Jews,  marriages  be- 
tween, 31. 

Chromation,  carrier  of  heredity,  40. 

Climate  of  tropics,  143. 

Climate,  127,  etc. 

Clitoridis  titillativa,  240. 

Clitoris,  size  of,  196. 

Club-foot,  hereditary,  explained,  54. 

Cohen  (haemophilia),  316. 

Cohnheim  (predisposition),  383. 

Cohnstein  (hyperemesis),  417. 

Coitus  and  sudden  death,  352. 

Coitus  a  posteriori,  therapeutical,  217. 

Collateral  heredity,  73. 

Collen  (tuberculosis  and   pregnancy), 

372- 

Colonies,  favoured,  165. 

Colonies,  German,  166. 

Coloured  races,  132,  etc. 

Columbat  (genital  organs),  196. 

Columella  (menstrual  blood),  247. 

Commandeur  (pernic.  anaemia),  317. 

Conception  in  arterio-sclerosis,  355. 

Conception,  prevention  of,  in  tuber- 
culosis, 397. 

Condamin  (hyperemesis),  416. 

Condom,  238. 

Condoms,  exciting,  239. 

Congenital  diseases,  47. 

Congenital  diseases,  not  hereditary,  48. 


Congenital    predisposition  to  disease, 

48. 
Congenital  and  inherited  diseases  and 

predispositions  to  disease,   by  Orth, 

37- 
Congenital  manifestations  of  disease, 

51. 

Congenital,  meaning  of  word,  37,  47. 
Congressus  reservatus,  234. 
Conjugal  intercourse  in  tuberculosis, 

39i- 

Connection  cure,  230. 

Consanguinity,  179. 

Consang.  marriages,  conclusions,  121. 

Consang.  marriages,  results  of,  99. 

Consang.  marriages  among  uncivilized 
nations,  95. 

Consanguinity  (statistics),  104,  etc. 

Consanguinity  in  marriage,  by  Kraus, 
79- 

Consanguinity.  See  also  Blood-rela- 
tionship. 

Constipation,  421. 

Constitutional  diseases  in  relation  to 
marriage,  265. 

Consumption,  364. 

Contagiousness  of  diabetes.  See  Dia- 
betes, transmissibility  of. 

Contamination,  44. 

Continence.  See  also  Sexual  absten- 
tion. 

Continence,  alleged  results  of,  228. 

Continence  and  the  married  state,  254. 

Continence,  effects  of,  21. 

Cordier  (on  beauty),  181. 

Cornet  (tubercle  bacillus),  380,  381. 

Cornet  (tuberculosis),  377. 

Corresponding  heredity,  75. 

Coste  (premature  sex.  interc.),  180. 

Creoles,  184. 

Crossed  heredity,  72. 

Cure  (ptyalism),  415. 

Curschmann  (sexual  function),  218, 
219,  223. 

Curschmann  (continence),  228,  230. 

Cutler  (consang.  marr.),  100. 

Cycling  in  sexual  hygiene,  242. 

Cylindruria,  446. 

Cyr  (gall-stones),  434. 

Czempin  (tuberculosis  and  pregnancy), 
373- 


Da  Costa  (premature  labour  in  heart 
disease),  339. 

Damian-Georg  (prolificness),  201. 

Daremberg  (tuberculosis  and  mar- 
riage), 370. 

Darwin  (beauty),  181. 

Darwin  (consang.  marr.),  99. 

Darwin's  "gemmules,"  67. 

Darwin  (hetarism),  179. 

Darwin  (proportion  of  sexes),  178. 


482 


INDEX 


Darwin  (race-mixture),  184. 

Darwinian  theory,  9. 

Daubler  (acclimatisation,  etc.),  151. 

Daubler  (climate,  etc.),  131. 

Deaf-mutism,  andconsang.  marr.,  101. 

Death,  sudden,  during  coitus,  352. 

Decandolle  (on  "  Kind"),  182. 

Dechambre  (consang.  marr.),  99. 

Defects,  inherited,  of  germicidal  cells, 
30. 

Degeneration,  physical  and  predis- 
position to  mental  disease,  51. 

De  la  Camp  (heart  and  disease),  325, 
326. 

Delage  (latent  heredity),  74. 

Depage  (pyelitis),  469,  470. 

Deparcieux  (mortality  of  monks  and 
nuns),  20. 

De  Rochebrune  (miscarriages),  202. 

Dercum's  Disease,  286. 

Determinants  of  Wrissmann,  60. 

Determination  of  the  pregnancy  owing 
to  disease,  255. 

Devay  (consang.  marr.),  99. 

Devay  (hered.  hexadactylism),  52. 

Diabetes  and  lactation,  270. 

Diabetes  and  marriage,  summary 
directions,  278. 

Diabetes  and  premature  labour,  275. 

Diabetes  and  the  generative  faculty, 
275. 

Diabetes,  influence  of,  on  the  offspring, 
276. 

Diabetes  in  married  women,  271. 

Diabetes  insipidus,  279. 

Diabetes  mellitus,  266. 

Diabetes  mellitus  and  marriage,  268. 

Diabetes,  transmissibility  of,  in  mar- 
ried life,  271. 

Dickinson  (nephritis),  458. 

Diday  (bacteriorrhoea),  225. 

Diehl  (blood  disease),  311. 

Dietrich  (gastritis  phlegmonora),  419. 

Digestive  disorders  and  the  contrac- 
tion of  marriage,  437. 

Digestive  functions  and  pregnancy, 
411. 

Digestive  functions  and  puerperium, 
411. 

Digestive  functions  of  husband,  in- 
fluence of  marriage  on,  410. 

Digestive  functions  of  wife,  influence 
of  marriage  on,  411. 

Digestive  organs,  diseases  of,  in  rela- 
tion to  marriage,  by  Ewald,  407. 

Dilatation  of  the  veins,  357. 

Diphtheria  and  heart  disease,  345. 

Disease,  marriage  and,  7,  9. 

Disease  and  pregnancy,  251. 

Diseases,  hereditary.  See  hereditary 
diseases. 

Disease,  meaning  of  word,  37,  44. 

Diseases  of  continence  or  abstinence, 
228,  229. 


Dohrn  (effect  of  pregnancy  on  the 
thorax),  333. 

Dohrn  (premature  labour  in  heart  dis- 
ease), 340. 

Dohrn  (tuberculosis  and    pregnancy), 

374- 

Don  Juan,  220. 

Donner  (sex.  interc.  during  intoxica- 
tion), 218. 

Douglas  (acute  yellow  atrophy),  432. 

Dubreuil  (tuberculosis  and  pregnancy), 
372. 

Ducrest  (heart  disease  and  pregnancy), 
330. 

Dulberg  (acute  yellow  atrophy),  432. 

Duplay  and  Dieu  (male  maturity),  173. 

During  Pasha  (syphilis),  187. 

Durosiez  (heart  disease  and  preg- 
nancy), 330. 

Dutch  as  colonists,  148,  152. 

Dysentery,  162. 

Dyspareunia,  217. 

Dyspeptic  phenomena,  419. 


Eclampsia,  456,  461. 

Economic  conditions,  effects  of,  on  off- 
spring, 28. 

Edleffsen  (constipation),  421. 

Egyptians,  consang.  marr.  among,  95. 

Eisenhardt  (hernia),  422. 

Eisenhardt  (gynaecol.  diseases),  413. 

Elberskirchen  (sexual  orgasm  in 
women),  217. 

Elephantiasis,  lymphangiectodes,  358. 

Ellinger  (tuberculosis  and  lactation), 
376. 

Ellis  (sexual  periodicity,  etc.),  218,  224. 

Emin  Pasha  (climate,  etc.),  144. 

Emissions,  229. 

Emphysema,  402. 

Endemic  diseases,  153. 

Endogamy,  81. 

England,  and  consang.  marriages,  92. 

English  as  colonists,  148,  152. 

Enteric  fever,  425. 

Enteroptosis,  419. 

Erb  (frequency  of  sex.  interc.),  219,  220. 

Erman  (marr.  age),  175. 

Esmarch  (case  of  material  impression), 
56. 

Essence  of  marriage,  10. 

Eulenberg  (frequency  of  sex.  interc.), 
220,  228. 

Eulenberg  (interrupted  coitus),  234,  236. 

Eulenberg  (optional  sterility),  233. 

Eulenberg  (sex.  neurasthen.),  223. 

Eulenberg  (travelling,  as  a  sexually 
hygienic  measure),  241. 

Eurasians,  185. 

Ewald  (appendicitis),  424. 


INDEX 


483 


Ewald,  diseases  of  digestive  organs  in 

relation  to  marriage,  407. 
Ewald  (gastritis),  419. 
Ewald  (haematemesis),  418. 
Excess,  sexual.     See  Sexual  excess. 
Exciting  condoms,  239. 
Exercise,    muscular.       See    Muscular 

exercise. 

Exner  (re-absorption  of  semen),  20. 
Exner  (hereditary  cicatricial  changes), 

54- 

Exophthalmic  goitre,  346. 
Eye  diseases  and  consang.  marr. ,  100. 
Eykman  (climate,  etc.),  133,  134. 


Faeces  as  infecting  medium  of  tuber- 
culosis, 381. 

Family  heredity,  30. 

Family  predisposition,  46. 

Family  practitioner,  consulting  advan- 
tages of,  12. 

Fatty  heart,  349. 

Favoured  colonies,  165. 

Fehling  (eclampsia),  456. 

Fehling  (nephritis),  454,  455,  458,  464. 

Fehling  (phlegmasia),  358. 

Feibes'  "protector,"  237. 

Felkin  (acclimatis),  164. 

Fellner  (acute  yellow  atrophy  of  liver), 

431- 

Fellner  (appendicitis),  423. 
Fellner  (blood  diseases),  310. 
Fellner  (bronchitis),  403. 
Fellner  (diabetes),  270. 
Fellner  (haematemesis),  417. 
Fellner  (heart  disease  and  pregnancy), 

331,  332,  337,  341,  344- 
Fellner  (lactation  and  heart  disease), 

35i- 

Fellner  (leukaemia),  316. 
Fellner  (nephritis),  451,  455,  460,  461, 

462,  464. 

Fellner  (ptyalism),  415. 
Fellner  (pyelitis),  468,  469. 
Females  and  acclimatisation,  141. 
Females,  beauty  of,  180. 
Ferdy  (condoms),  239. 
Ferdy  (optional  sterility),  233. 
Fere  (dangers  of  sex.  interc.),  218. 
Fere  (Dercum's  disease),  287. 
Fiebig  (climate,  etc.),  145. 
Fieux  (hereditary  albuminuria),  465. 
Finger  (pseudo-gonorrhoea),  225. 
Finke  (menstruation),  172. 
Finsch  (cross-products),  182. 
Fischer  (haemophilia),  316. 
Fischer  (nephritis),  453. 
Fischer  (tubercle  bacillus),  381. 
Fischer-Dilckelmann  (sex.  interc.),  211. 
Flaischlen  (nephritis),  454,  455. 
Floating  kidney,  466. 
Flourens  (on  "  Kind"),  183. 


F.  L's.     See  Condom. 

Fluegge  (tubercle  bacillus),  381. 

Foetal  diseases,  47. 

Foetid   bronchiectasis   and   bronchitis, 

404. 

Force  in  sexual  intercourse,  214. 
Forel  (continence),  228. 
Forms  of  marriage,  178. 
Fordyce  (haemophilia),  311. 
Forster  (haemophilia),  316. 
Fournier  (hereditary  albuminuria),  465. 
Frankel  (acromegaly),  289. 
Fraenkel  (appendicitis),  424. 
Fraenkel  (asthma),  398,  399. 
Fraenkel  (hygiene  of  woman),  226. 
Fraenkel  (tuberculosis  and  pregnancy), 

373,  375- 

Frank  (jaundice),  430. 

Frank  (tuberculosis  and  pregnancy), 
372. 

Frank,  P.  (infectiousness  of  tuber- 
culosis), 377. 

French  as  colonists,  148. 

Frerichs  (diabetes),  276. 

Freud  (interrupted  coitus),  236. 

Freud  (optional  sterility),  233. 

Freund  (favourable  influence  of  mar- 
riage),  435. 

Freund  (hyperemesis),  417. 

Freund  (ileus),  427. 

Freund  (parametritus),  426. 

Freund  (perfor.  gastr.  ulcer),  418. 

Freund  (phlegmasia),  358. 

Freund  (predisposition  to  tuberculosis), 
384- 

Freund  (ptyalism),  415. 

Freund  (shape  of  thorax),  50. 

Freyhan  (nephritis),  454. 

Friedmann  (experiments  on  germinal 
infection),  43. 

Fritsch  (heart  disease  and  pregnancy), 
330. 

Fritsch  (race-mixture),  184,  185. 

Functional  acquisitions,  hereditary 
transmission  of,  69. 

Filrbringer  (nephritis),  450. 

Fiirbringer  (sexual  hygiene  in  married 
life),  209. 

Fiirbringer  (tuberculosis  and  mar- 
riage), 369. 


Gaertner  (transmission  of  tubercu- 
losis), 383. 

Gaertner  (tubercle  bacillus),  380. 

Galen  (infectiousness  of  tuberculosis), 
377- 

Galippe  (sex  and  teeth),  412. 

Gall-stones,  433. 

Galtier  (tubercle  bacillus),  381. 

Garrod  (gout),  280. 

Gastric  catarrh,  420. 

Gastric  ulcer,  perforation  of,  418. 


484 


INDEX 


Gastritis  phlegmonosa,  418. 

Gastroptosis,  419. 

Gattel  (interrupted  coitus),  236. 

Gegenbauer  (hexa-dactylism),  52. 

Gemtnules,  67. 

Generative  faculty  and  diabetes,  275. 

Genital  organs  in  various  nations,  196. 

Gerhardt  (heart  disease  and  preg- 
nancy), 330. 

Gerhardt  (prophylactic  abortion),  393. 

Gerhardt  (tuberculosis  and  lactation), 
376. 

Gerhardt  (tuberculosis  and  marriage), 
368,  391. 

Gerhardt  (tuberculosis  and  pregnancy), 
373- 

Gerhardt  (universality  of  tuberculosis), 
367- 

German  colonies,  climate  of,  166. 

Germans  as  colonists,  149,  152. 

Germ-cells,  maternal,  impregnation 
of,  58. 

Germ-cells,  relations  between,  and 
body,  65. 

Germinal  cells,  inherited  defects  of, 
30. 

Germinal  infection,  43. 

Germ-plasma,  42. 

Germ-plasma,  alterations  in,  56. 

Germ-variation,  primary  and  second- 
ary, 61. 

Germ-variation,  primary,  in  free  germ- 
cells,  63. 

Germ-variations,  primary,  in  the  germ- 
glands,  64. 

Germ-variation,  secondary,  65. 

Germ-variation  through  amphimixis, 
61. 

Gland  condoms,  239. 

Glogner  (climate,  etc.),  133. 

Glossitis,  415. 

Gluteal  region,  variations  of,  196. 

Glycosuria  e  saccharo,  268. 

Glycosuria  ex  amylo,  268. 

Glycosuria  in  pregnancy  and  child- 
bed, 267. 

Gocht  (haemophilia),  316. 

Goethe  (married  state),  14. 

Goitre,  exophthalmic,  346. 

Goldscheider  and  Jacob  (physical  treat- 
ment of  potency),  240. 

Golgi  (malaria),  155. 

Gonorrhoea,  189. 

Gottstein  (predisposition),  384. 

Gout  and  marriage,  279. 

Gout  and  plumbism,  281. 

Gout  and  syphilis,  281. 

Gout,  heredity  of,  280. 

Grandi  amatori,  220. 

Grandidier  (haemophilia),  311,  312,  313, 
315- 

Grave's  disease,  266,  346. 

Green  (leukaemia),  317.! 

Gregory  I.  (consang.  marr.),  86. 


Griesinger  (diabetes),  276. 

Griesinger  (yellow  fever),  158. 

Griquas,  184. 

Grisolle  (tuberculosis  and  lactation), 
376. 

Grisolle  (tuberculosis  and  pregnancy), 
372. 

Gruber  (diabetes),  276. 

Gruber  (hygienic  significance  of  mar- 
riage), 17. 

Gusserow  (heart  disease  and  preg- 
nancy), 396. 

Gusserow  (tuberculosis  and  heart  dis- 
ease), 375. 

Gutierrez  (pelvis),  195. 

Guttzeit  (orgasm  in  women),  217. 

Gyurgovetchky  (continence),  229. 

Gyurgovetchky  (frequency  of  sex. 
interc.),  220. 

Gyurgovetchky    (interrupted     coitus), 

235- 
Gyurgovetchky  (travelling),  241. 

H 

Hack  (asthma),  399. 
Haematemesis,  417. 
Haemoglobinaemia,  309. 
Haemoglobinuria,  309. 
Haemophilia,  311. 
Haemophilics  and  marriage,  315. 
Haemorrhagic  diathesis,  309. 
Haemorrhoids,  357,  428. 
Hahn  (nephritis),  454. 
Haidlin  (pancreatitis),  429. 
Hamburger    (tuberculosis    and    preg- 
nancy), 373,  375- 
Hamburger    (prophylactic     abortion), 

395- 

Hamburger  (tuberculosis  in  the  off- 
spring), 385. 

Hammond  (case  of  sexual  excess),  223. 
Hanau  (aspiration  tuberculosis),  375. 
Hansemann     (case    of     laceration    of 

vagina),  215. 

Hartman  (male  maturity),  173. 
Hartsen  (marriage  and   tuberculosis), 

368. 

Hasse  (optional  sterility),  228,  233. 
Havelburg  (climate,    etc.),  127. 
Hay-fever,  400. 
Heart  disease  and  artificial  premature 

labour,  339. 

Heart  disease  and  labour,  335. 
Heart  disease  and  lactation,  351. 
Heart  disease  and  pregnancy,  329. 
Heart  disease  and  sexual  intercourse, 

350. 

Heart,  disease  of  the,  324. 
Heart,  fatty  degeneration  of,  349. 
Heart,   weakness   of,    after   infectious 

diseases,  345. 

Hecker  and  Buhl  (fatty  liver),  433. 
Hegar  (optional  sterility),  233. 


INDEX 


485 


Hegar  (sex.  desire,  etc.),  227,  228,  229. 

Hegar  (sex.  interc.),  214. 

Helarism,  178. 

Helfft  (acclimatisation,  etc.),  149. 

Hellwig  (prevention  of  venereal  dis- 
eases), 14. 

Hensen  (menstr.),  171. 

Hepatoptosis,  419. 

Hereditary  diseases  (there  are  none), 
48. 

Hereditary  predisposition  .in  tuber- 
culosis, 49. 

Heredity,  collateral,  73. 

Heredity,  corresponding,  75- 

Heredity,  crossed,  72. 

Heredity,  essence  of,  39. 

Heredity,  hetero-polymorphous,  75. 

Heredity,  homo-hetero-polymorphous, 

75- 

Heredity,  homo-sexual,  73. 

Heredity,  influence  of,  80. 

Heredity,  latent,  73. 

Heredity  of  gout,  280. 

Heredity,  potency  of,  71. 

Heredity,  potential,  63. 

Heredity,  summary  on,  71. 

Heredity  through  several  generations, 
30. 

Heredity,  variability  of,  72. 

Hereditary  predisposition,  12. 

Hereditary  transmission  of  acquired 
peculiarities,  59. 

Hereditary  transmission  of  anomalies 
and  malformations,  52. 

Hereditary  transmission  of  chemical 
changes,  70. 

Hereditary  transmission  of  functional 
acquisitions,  69. 

Hereditary  transmission  of  mutila- 
tions, 67. 

Herniae,  422. 

Herrlich  (nephritis),  455. 

Hertwig  (impregnation),  63. 

Herzen  (continence),  228. 

Heule  (negroes),  134. 

Hilbert  (leukaemia),  317. 

Hildebrandt  (intestinal  obstruction), 
427. 

Hirsch  (acclimatisation),  128. 

Hirsch  (consang.  marr. ),  121. 

Hirsch  (malaria),  156. 

Hirsch  (tuberculosis),  189. 

Hirschberg  (consang.  marr.),  101. 

Hirt  (interrupted  coitus),  236. 

Historical  sketch  on  marriage,  5,  etc. 

Hodgkin's  disease,  359. 

Hoerschelmann  (continence),  228. 

Hoffmann  (premature  labour  in  heart 
disease),  339. 

Hofmeier  (nephritis),  454,  458,  461,  464. 

Holidays,  as  a  sexually  hygienic  meas- 
ure, 241. 

Homer  (haemophilia),  313. 

Hoslin  (haemophilia),  313,  316. 


Ho'slin  (interrupted  coitus),  235. 
Hottentots,  184. 
Hottentot  apron,  196. 
Howe  (consang.  marr.),  99. 
Huchard  (arterio-sclerosis),  353. 
Huchard  (gall-stones),  434. 
Husband,  choice  of,  31. 
Huth  (consang.  marr.),  96,  101. 
Hygiene  in  tropics,  144. 
Hygiene  of  pregnancy,  255. 
Hygiene,  sexual.     See  Sexual  hygiene. 
Hygienic  advantages  of  marriage,  18. 
Hygienic  significance  of  marriage,  by 

Cruder,  17. 

Hymen,  rupture  of,  68,  215. 
Hyperemesis,  415. 

I 

Icterus  gravidarum  gravis,  430. 

Idioplasma,  42. 

Ileus,  426. 

Illegitimate  births,  restriction  of,  24. 

Illegitimate  children,  mortality  of,  25. 

Immunity,  384. 

Imogen,  Shakespeare's,  216. 

Impotence,  psychical  treatment  of, 
242. 

Impregnation,  58. 

Impregnation  of  maternal  germ-cells, 
58. 

In-and-in-breeding,  81. 

In-and-in-breeding  of  wild  animals,  98. 

Incest,  6,  85. 

Individual  predisposition,  46. 

Infantile  marriages,  180. 

Infection  distinguished  from  infectious 
disease,  44. 

Influenza  and  heart  disease,  345. 

Inherited  defects  of  germinal  cells,  30. 

Inherited  diseases,  47. 

Inherited  predisposition  to  disease,  48. 

Inherited,  meaning  of  word,  37,  42. 

Inherited  peculiarities,  26. 

Injuriousness  of  marriage,  25. 

Inoculation,  protective,  162. 

Insanity,  resulting  from  consang.  mar- 
riage, 103. 

Intercourse,  sexual.  See  Sexual  in- 
tercourse. 

Interrupted  intercourse,  234,  351. 

Intestinal  catarrh,  420. 

Intestines,  diseases  of,  409. 

Intestines,  laceration  of,  420. 

Introduction,  by  Senator,  5. 

Involution-period,  sexual  interc.  dur- 
ing, 232. 

Iroquois.  marriage  among,  94. 

Irrigations,  vaginal.  See  Vaginal 
irrigation. 

Israel  (pyelitis),  469. 

Israel  (tubercul.  of  kidneys),  470,  471, 
472,  477- 


486 


INDEX 


J 

Jablotschkoff  (diabetes),  277. 

Jacob.     See  Goldscheider. 

Jacob   and    Pannwitz   (contagiousness 

of  tuberculosis),  378. 
Jacob  and  Pannwitz  (tuberculosis  and 

lactation),  376. 
Jacob  and  Pannwitz  (tuberculosis  and 

marriage),  391. 
Jacob  and  Pannwitz  (tuberculosis  and 

pregnancy),  373,  375. 
Jacob  and  Pannwitz  (tuberculosis  and 

sex.  interc.),  370. 
Jager  (consang.  marr.),  101. 
aggard  (leukaemia),  317. 
ani  (tubercle  bacillus),  379. 
apan  and  consang.  marriages,  43. 
arret  (nephritis),  456. 
aundice,  429. 

aworsky  (pernic.  anaemia),  317. 
Jeoffroy  (Grave's  disease),  347. 
Jews  (acclimatisation  of),  147. 
Jews   and   Christians,    marriages    be- 
tween, 31. 

Jews  and  consang.  marriages,  91. 
Joachim  (menstr.),  170. 


K 

Kaltenhach  (hyperemesis),  416. 
Kaltenbach  (sex.  interc.),  214. 
Kaminer  vdiseases  of  the   respiratory 

organs),  363. 
Kaminer  (tuberculosis  and  pregnancy), 

373,  375- 

Katz  (tuberculosis),  190. 
Kehrer  (haemophilia),  315. 
Kehrer    (toothache    and     pregnancy), 

412. 

Kidd  (haemophilia),  311,  316. 
Kidney,  amyloid  disease  of,  466. 
Kidney,  movable,  466. 
Kidney,  humours  of,  474. 
Kidneys,  action  of,  during  pregnancy, 

333- 
Kidneys,    diseases   of,    in    relation   to 

marriage,  by  Richter,  443. 
Kidneys,  tuberculosis  of,  470. 
Kind,  definition  of,  182. 
Kirchner  (tuberculosis  and  marriage), 

368. 

Kirchner  (tuberculous  changes),  380. 
Kirchner.     See  Riffel. 
Kirk  (dental  caries),  412. 
Kisch    (interrupted     intercourse     and 

heart  disease),  351. 
Kisch  (interrupted  coitus),  236. 
Kisch  (dyspareunia),  217. 
Kisch  (obesity),  283,  285. 
Kisch  (pessaries),  238. 
Klebs  (fatty  liver),  433. 
Kleinwachter  (prophylactic  abortion), 

394- 


Kleinwachter  (nephritis),  457. 
Kleinwachter    (pregnancy   and    inter- 
course), 225. 
Klemperer.     See  Leyden. 
Klunzinger  (marr.  age),  175. 
Knapp  (movable  kidney),  467. 
Koblanck  (nephritis),  454,  455. 
Koch  (haemophilia),  312,  316. 
Koch  (malaria),  155,  156. 
Koch   (transmission   of   tuberculosis), 

383- 

Koch's  tuberculin,  366. 

Kogel  (menstruation),  172. 

Kohl  (consang.  marr.),  99. 

Konig  (tubercl.  of  kidneys),  472,  476. 

Kb'nig  (appendicitis),  424. 

Kossmann  (abortion),  392. 

Kossmann  (menstruation,  etc.,  in  rela- 
tion to  marriage),  245. 

Krafft-Ebing  (continence),  229. 

Krafft-Ebing  (inherited  (?)  insanity),  57. 

Krafft-Ebing  (interrupted  coitus),  234, 
235- 

Krafft-Ebing  (orgasm  in  woman,  etc.), 
217,  224. 

Krascheminkoff  (Kamtschatka),  96. 

Kraus  (consanguinity  in  marriage),  79. 

Krause  (negroes),  134. 

Krieger  (menstruation),  170. 

Kroenig  (continence),  228. 

Krusemann  (Baduwis),  95. 

Krzyminski  (nephritis),  455. 

Ktichenmeister  (pregnancy  and  tuber- 
culosis), 374. 

Kllchenmeister  (effect  of  pregnancy  on 
the  lungs),  333. 

Ktilz  (diabetes),  277. 

Ktllz.     See  OppUr. 

Ktilz  (diabetes),  273. 

Kutisk  (hernia),  422. 

Kuttner  (prophylactic  abortion),  395. 

Kuttner  (tuberculosis  and  pregnancy), 
373- 


Labour  and  heart  disease,  335. 
Labour    and     maternity    institutions, 

258. 

Lactation,  260. 
Lactation  and  asthma,  401. 
Lactation  and  diabetes,  270. 
Lactation  and  heart  disease,  351. 
Lactation  and  tuberculosis,  376. 
Lactation,  etc.,  in  relation  to  marriage, 

245- 

Lactation,    prohibition    of,    in    tuber- 
culosis, 397. 

Lactation,  prolonged,  198. 

Lactosuria,  267. 

Ladinos,  184. 

Lallemand  (sexual  abstinence),  228. 

Landau  (splanchnoptosis),  420. 

Laqueur  (consang.  marr.),  100. 


INDEX 


487 


Larcher  (pregnancy  and  heart  disease), 

329. 
Laryngeal  and  pulmonary  tuberculosis, 

363- 

Larynx,  malignant  tumours  of,  401. 
Latent  heredity,  73. 
Laucereaux  (heart  disease),  328. 
Laveran  (malaria),  155. 
Lavoisier  (climate,  etc.),  138. 
Leber  (consang.  marr.),  100,  121. 
Lecorche  (gout),  280. 
Lennander  (varicose  veins),  357. 
Leo  (diabetes),  272. 
Leube  (albuminuria),  448. 
Leucocytosis,  physiological,  251. 
Leukaemic  adenia,  359. 
Leuvet  (transmission  of  tuberculosis), 

384- 

Le  Vaillant  (race-mixture),  184. 
Leyden  (myocarditis),  345. 
Leyden  (nephritis),  452,  455,  457,  458. 
Leyden  (pregnancy  and  heart  disease), 

329- 
Leyden  (pregnancy  and  tuberculosis), 

372,  373- 
Leyden   (prophylactic    abortion),    393, 

396- 

Leyden  (tubercle  bacilli),  365. 
Leyden   (tuberculosis   and    marriage), 

369- 
Leyden  (tuberculosis  and  pregnancy), 

374- 

Leyden  and  Klemperer  (physical  treat- 
ment of  potency),  240. 
Leyden  and  Wolff  (diseases  of  vascular 

system  in  relation  to  marriage),  321. 
Liaisons,  211. 

Liebreich  (consang.  marr.),  101. 
Lind  (climate,  etc.),  143. 
Lipomatosis  universalis,  283. 
Liszt  (prevention  of  venereal  disease), 

14. 

Literature  on  consanguinity,  123. 
Literature  on  congenital  and  inherited 

diseases,  76. 

Litten  (haemophilia),  316. 
Litzmann  (menstr.),  171. 
Litzmann  (pelvis),  195. 
Liver,  abcess  of,  432. 
Liver,  acute  yellow  atrophy  of,  430. 
Liver,  cancer  of,  434. 
Liver,  cirrhosis  of,  432. 
Liver,  disease  of,  429. 
Liver,  fatty,  432. 
Livingstone  (syphilis),  189. 
Livoff  (ptyalism  in  pregnancy),  413. 
Lode  (spermatozoe),  21. 
Loewy  and  Richter  (obesity),  284. 
Lohlein  (heart  disease  and  pregnancy), 

330. 

Lohlein  (nephritis),  454,  459,  460. 
Lohlein    (premature   labour   in    heart 

disease),  340. 
Lb'hlein  (ptyalism),  415. 


Lo'hnberg  (prophylactic  abortion),  395. 
Lohnberg     (tuberculosis     and     preg- 
nancy), 373. 

Lombroso's  "  homo  delinquens,"  75. 
Lomer  (acute  yellow  atrophy  of  liver), 

43i. 

Longevity  of  married  men,  23. 
Lorenz  (blood-relationship),  93. 
Lorenz  (pedigrees),  83. 
Lessen  (haemophilia),  311,  314,  315. 
Low  (malaria),  155. 
L6wenfeld  (condoms),  239. 
Lowenfeld  (continence),  228,  230. 
Lowenfeld    (interrupted    coitus),    235, 

236. 

Lowenfeld  (optional  sterility),  233. 
Lo'wenfeld  (sexual  life),  218,  219,  220, 

222,  223. 
Lubarsch   (placental    transmission    of 

disease),  40. 

Lubbock  (helarism),  178. 
Ludwig  (diabetes),  267. 
Lung.     See  also  Pulmonary. 
Lung,  actinomycosis  of,  402. 
Lung,  echinococcus  of,  402. 
Lung,  malignant  tumours  of,  401. 
Lung,  syphilis  of,  402. 
Luther  (frequency  of  sex.  interc.),  219. 
Luxurious   livers   and    heart  disease, 

349- 

Lymphangioma,  358. 
Lymphatic  pseudo-leukaemia,  359. 
Lymphatics,  diseases  of,  358. 
Lymphatics,  sarcoma  of,  359. 
Lymphectasis,  358. 
Lymphoma,  malignant,  359. 
Lyon  (bacteriorrhcea),  225. 

M 

Macdonald  (heart  disease  and  preg- 
nancy), 330,  336,  339. 

Magnus  (exogamy),  85. 

Magnus  (consang.  marr.),  101. 

Mahillon  (varix),  358. 

Main  (consang.  marr.),  85. 

Malaria,  154. 

Male  sex,  duration  of  sexual  function 
in,  172. 

Malformations  and  anomalies,  heredi- 
tary transm.  of,  52. 

Malformations,  as  result  of  consang. 
marriages,  104. 

Malthus  (fruitfulness),  177. 

Malthusian  principles,  233. 

Manifestations  of  disease,  congenital, 
Si- 

Manley  (hernia),  422. 

Mantegazza  (consang.  marr.),  99. 

Mantegazza  (frequency  of  sex.  interc.), 
220. 

Mantegazza  (menstr.),  171. 

Maragliano  (prophylactic  abortion), 
393,  etc. 


488 


INDEX 


Maragliano  (tuberculosis  and  preg- 
nancy), 375. 

Maragliano  (tuberculosis  in  the  off- 
spring), 385. 

Marestang  (climate,  etc.),  138. 

Marey  (arterial  pressure).  331. 

Maria  Theresia,  240. 

Marriage  and  acromegaly,  288. 

Marriage  and  asthma,  399. 

Marriage  and  diabetes  mellitus,  268. 

Marriage  and  diabetes.  Summary,  278. 

Marriage  and  gout,  279. 

Marriage  and  myxcedema,  287. 

Marriage  and  nephritis,  449. 

Marriage  and  obesity,  283,  etc. 

Marriage  and  tuberculosis,  387. 

Marriage,  anthropological  observa- 
tions on,  192. 

Marriage,  as  cause  of  disease,  7. 

Marriage,  as  transmitter  of  disease,  8. 

Marriage,  effect  of,  on  offspring,  8. 

Marriage,  effect  of,  on  disease,  10. 

Marriage,  essence  of,  10. 

Marriage-forms,  178. 

Marriage,  historical  sketch  on,  5,  19. 

Marriage,  hygienic  advantages  of,  18. 

Marriage,  hygienic  significance  of,  17. 

Marriage,  influence  of,  on  digestive 
functions  of  husband,  410. 

Marriage,  influence  of,  on  digestive 
functions  of  wife,  411. 

Marriage,  injuriousness  of,  25. 

Marriage  in  the  tropics,  185. 

Marriage  of  blood-relations,  62. 

Marriage,  origin  of,  178. 

Marriage,  prohibition  of,  in  heart  dis- 
ease, 344. 

Marriage,  prohibition  of,  in  nephritis, 
462. 

Marriage,  relations  of,  to  health  and 
disease,  7. 

Marriage,  restriction  of,  13. 

Marriageable  age,  173. 

Marriages,  infantile,  180. 

Married  individuals,  longer  life  of,  18. 

Married  life,  sexual  hygiene  of,  209. 

Martin  (climate,  etc.),  140. 

Martin  (pelvis),  194. 

Martins  (tuberculosis),  366. 

Marx  (appendicitis),  425. 

Masing  (continence),  228. 

Mass-acclimatisation,  140. 

Massoin  (artificial  atrophy  of  spleen), 
68. 

Maternal  impressions  of  pregnanf 
women,  54. 

Maternal  influence  of  foetus,  54. 

Maternity  institutions  and  labour,  258. 

Matthieu  (removable  kidney),  467. 

Maturity,  sexual,  169. 

May  and  December  marriages,  222. 

Mayet  (continence),  228. 

Mayet  (consang.  marr.),  104,  etc. 

Mayr  (cons,  marr.),  101. 


McArthur  (appendicitis),  425. 
Mediastinum,   malignant    tumors    of, 

401. 

Meinhold  (haemoglobinuria),  430. 
Meissner  (laceration  of  intestines),  421. 
Mendel  (continence),  228. 
Mendelsohn    (sex.   interc.    and    heart 

disease),  350. 
Menopause,  171. 
Mensinga.     See  ffasse. 
Menstrual  blood,  toxicity  of,  247. 
Menstruation,  169. 
Menstruation  and  matrimonial  troubles 

250. 

Menstruation  and  wedding-day,  248. 
Menstruation,  commencement  of,  169. 
Menstruation,  duration  of,  in  various 

races,  169,  etc. 
Menstruation,  end  of,  171. 
Menstruation,    pregnancy,    child-bed, 

lactation  in  relation  to  marriage,   by 

Kossmann,  245. 
Menstruation,  sexual  intercourse  and, 

223. 
Mental  diseases,   reappearance   of,  in 

offspring,  29,  30. 
Messalina,  220. 
Mestees,  184. 

Metabolic  diseases  in  relation  to  mar- 
riage, 265. 

Metallic  intoxications,  effect  of,  in  off- 
spring, 28. 

Meuse  (climate,  etc.),  131. 
Meuse  (syphilis),  187. 
Meyer  (heart  disease),  328. 
Michaelis  (heart  disease),  328. 
Milk,  transmission  of  disease  through, 

40. 

Minkowsky  (heart  disease),  328. 
Miscarriages,     accidental,    anthropol. 

observations  on,  201. 
Mitchell  (cons,  marr.),  99. 
Mixture  of  races,  149,  182. 
Mobius  (Grave's  disease),  346. 
Moricke  (nephritis),  458. 
Mohammed  (frequency  of  sex.  interc.), 

219. 

Moll  (sexual  desire),  229. 
Mondiere  (menstruation),  172. 
Monks  and  nuns,  mortality  of,  20. 
Morbus  maculosus  Werlhofii,  310. 
Moren  (cons,  marr.),  107. 
Morgan  (cons,  marr.),  85,  96. 
Moritz  (variococele),  358. 
Mortality  among  illegitimate  children, 

25- 

Mosaic  law  on  marriage,  6. 
Mouth,  affections  of,  and  pregnancy, 

411. 

Movable  kidney,  466. 
Mulattoes,  184. 
M tiller  (hernia),  422. 
Mliller  (sex.  interc.),  214. 
Mtiller  (spleen),  434. 


INDEX 


489 


Munk  (lactation  and  tuberculosis),  376. 

Muscular  exercise,  as  sexually  hy- 
gienic measure,  241. 

Mutilations,  hereditary  transmission 
of,  67. 

Mynlieff  (nephritis),  453,  458,  459. 

Myocarditis,  chronic,  348. 

Myocarditis,  toxic,  345. 

Myocardium,  diseases  of  the,  345. 

Myocardium,  incompetence  of  the,  349. 

N 

Naegeli  (recovery  from  tuberculosis), 

390. 

Naegeli  (tuberculosis),  365. 
Naegeli  (tuberculous  changes),  380. 
Nationality,  127,  etc. 
Naunyn  (diabetes),  273,  277. 
Naunyn  (gall-stones),  434. 
Naunyn  (glycosuria),  268. 
Necessity  of  sexual  intercourse,  20. 
Negroes  and  consumption,  192. 
Neo-malthusian  principles,  233. 
Nephrectomy  and  marriage,  475. 
Nephritis,  444. 
Nephritis  and  marriage,  449. 
Nephritis   and  marriage.      Summary, 

465- 

Nephritis,  chronic,  448,  458. 
Nephritis,  effects  of,  on  the  offspring, 

464. 
Nephritis,   interruption  of   pregnancy 

in,  462. 

Nephritis  of  pregnancy,  451. 
Nephritis,  prohibition  of  marriage  in, 

462. 

Nephrolithiasis,  474. 
Nephroptosis,  419. 
Nero,  220. 

Nervous  complaints  and  digestive  dis- 
turbances, 408. 
Nervous  diseases,  reappearance  of,  in 

offspring,  29,  30. 
Neurasthenia,  sexual,  222. 
Neuritis,  toxic,  345. 
Nicotine  and  heart  disease,  347. 
Niemeyer  (phthisis  and  tuberculosis), 

363- 
Non-connubial  intercourse  condemned, 

23- 

Noorden  (diabetes),  277. 
Noorden  (obesity),  283. 
Nuns.     See  Monks. 


O 

Obersteiner  (artificial  epilepsy),  69. 
Obesity  and  marriage,  283,  etc. 
Obesity  and  the  sexual  function,  284. 
Occlusive  pessaries,  anti-conceptional 

237. 

Octoroons,  185. 
Ofele  (optional  sterility),  233. 


Offspring,  advantage  to,  from  mar- 
riage, 24. 

Offspring  and  mental  diseases,  29. 

Offspring  and  nervous  diseases,  29,  30. 

Offspring  and  syphilis,  28. 

Offspring  and  tuberculosis,  28,  382. 

Offspring,  constitution  of,  26. 

Offspring,  effects  of  age  of  parents  on 
the,  27. 

Offspring,  effects  of  alcoholism  of  par- 
ents on  the,  29. 

Offspring,  effects  of  economic  condi- 
tions on  the,  28. 

Offspring,  effects  of  marriage  on  the,  8. 

Offspring,  effects  of  metallic  intoxica- 
tions on  the,  29. 

Offspring,  effects  of  nephritis  on  the, 
464. 

Offspring,  effects  of  parental  disease 
on  the,  28. 

Offspring,  effects  of  successive  preg- 
nancies on  the,  27. 

Offspring,  influence  of  diabetes  on  the, 
276. 

Offspring  of  anaemics,  305. 

Old  bachelors,  193. 

Old  husbands  and  young  wives,  222. 

Old-maidenhood,  229. 

Old  maids,  193. 

Olshausen  (vaginismus),  216. 

Onanism,  234. 

Onanismus  conjugalis,  234. 

Operations  on  kidney,  475. 

Oppenheim  (interrupted  coitus),  235. 

Oppenheim  (marr.  age),  175. 

Oppler  and  Kiilz  (diabetes),  271. 

Orgasm  in  man,  217. 

Orgasm  in  woman,  217. 

Origin  of  marriage,  178. 

Orschansky  (male  and  female  ances- 
tors), 73. 

Orschansky  (transformism),  75. 

Ortel  (haemophilia),  312. 

Orth  (congenital  and  inherited  dis- 
eases), 37. 

Orth  (transmission  of  characteristics), 
61. 

Oser  (diseases  of  pancreas),  429. 

Overexertion  and  heart  disease,  349. 


Pancreas,  diseases  of,  429. 

Pannwitz.     See  Jacob  and  Pannwitz. 

Parametritis  chronica  atrophicans,  426. 

Paratyphlitis,  423. 

Parental  disease,  effects  of,  on  off- 
spring, 28. 

Paroxysmal  lachycardia,  354. 

Pathological  conditions  in  children, 
not  always  congenital,  51. 

Patissier  (gout),  280. 

Pawlinoff  (nephritis),  459. 

Peacock  (heart  disease),  325,  330. 


490 


INDEX 


Peculiarities,  acquired.     See  Acquired 

peculiarities. 

Peculiarities,  inherited,  26. 
Peipers  (ancestors),  84. 
Peipers  (consanguinity),  93,  loi. 
Peliosis  rheumatica,  310. 
Pelvis  in  various  nationalities,  194. 
Perforation  of  gastric  ulcers,  418. 
Pericolitis,  421. 
Perier  (consang.  marr.),  99. 
Perisigmoiditis,  421. 
Peritoneum,  changes  in,  426. 
Peritonitis,  427. 
Perityphlitis,  423. 
Persians,  and  consang.  marr.,  95. 
Peruvians,  and  consang.  marr.,  95. 
Peschl  (marr.  age),  173. 
Pessaries,  occlusive,  anti-conceptional, 

237- 

Peter's  formula,  327. 
Petit  acclimatement,  128. 
Petit-blancs,  150. 
Peyer  (asthma),  400. 
Peyer  (interrupted  coitus),  236. 
Phillipps  (blood  diseases),  310. 
Phlebectasis,  357. 
Phlebitis,  356. 
Phlebo-sclerosis,  356. 
Phlegmasis  alba  dolens,  358. 
Phthisical  thorax,  50. 
Phthisis  and  tuberculosis  not  the  same 

thing,  363. 

Picca  of  pregnant  women,  253. 
Placenta!  infection,  39. 
Placental  toxins,  431. 
Plague,  161. 
Plato  (on  marriage),  6. 
Plato  (on  natural  selection),  9. 
Plehn  (climate,  etc.),  136,  166. 
Plehn  (malaria),  157. 
Pliny  (menstrual  blood),  247. 
Pliny  quoted,  128. 
Ploss-Bartels  (abortion),  205. 
Ploss-Bartels  (ampallangs),  240. 
Ploss-Bartels  (female  breasts),  197. 
Ploss-Bartels  (infantile  marriages),  180. 
Ploss-Bartels  (marr.  age),  173. 
Ploss-Bartels  (menstruation),  224,  227, 

247- 

Ploss-Bartels  (on  woman),  193. 
Ploss-Bartels  (optional  sterility),  234. 
Ploss-Bartels  (sexual  interc.),  212. 
Plumbism  and  gout,  281. 
Polyandry,  178. 
Polygamy,  178. 
Polyuria,  279. 
Ponfick  (heart  disease  and  pregnancy), 

332. 
Portal   (tuberculosis  and   pregnancy), 

372. 

Position  in  sexual  intercourse,  212,  226. 
Posner  (tubercle  bacillus),  380. 
Potency,  240. 
Potency  of  heredity,  71. 


Potential  heredity,  63. 

Practitioner.     See  Family  practitioner. 

Predisposition,  family,  46. 

Predisposition  for  acclimatisation,  141. 

Predisposition,  hereditary,  to  tuber- 
culosis, 49. 

Predisposition,  individual,  46. 

Predisposition  to  tuberculosis,  383. 

Predisposition  to  disease  (meaning  of 
word),  37,  44. 

Pregnancy  and  asthma,  400. 

Pregnancy  and  digestive  functions, 
411. 

Pregnancy  and  disease,  251. 

Pregnancy  and  disturbances  in  the 
lungs,  333. 

Pregnancy  and  heart  disease,  329. 

Pregnancy  and  tuberculosis,  372. 

Pregnancy  and  sexual  intercourse,  257. 

Pregnancy,  determination  of,  on  ac- 
count of  disease,  255. 

Pregnancy,  disorders  of,  250,  etc. 

Pregnancy,  hygiene  of,  255. 

Pregnancy  in  arterio-sclerosis,  356. 

Pregnancy,  in  relation  to  marriage, 
245,  250. 

Pregnancy,  interruption  of,  in  ne- 
phritis, 462. 

Pregnancy,  nephritis  and  artificial 
abortion,  456. 

Pregnancy,  nephritis,  451. 

Pregnancy,  prohibition  of,  in  heart 
disease,  345. 

Pregnancy,  psychosis  in,  257. 

Pregnancy,  sequelae  of,  336. 

Pregnancy,  sexual  intercourse  during, 
225. 

Premature  labour,  prophylactic,  in 
tuberculosis,  396. 

Premature  labour,  artificial,  in  heart 
disease,  339. 

Prevention  of  venereal  disease,  228. 

Preventive  intercourse,  232. 

Preventive  sexual  intercourse  con- 
demned, 34. 

Prinzing  (mean  expectation  of  life),  24. 

Prohibition  of  marriage  between  blood- 
relations,  85. 

Prohibition  of  marriage  in  heart  dis- 
ease, 344. 

Prolapse  of  rectum,  428. 

Prolificness,  199. 

Prophylaxis  in  tuberculosis  of  married 
persons,  392. 

Protective  agencies   of   human   body, 

45- 

Protective  inoculation,  162. 
Protector,  237. 

Psychical  treatment  of  impotence,  242. 
Psychosis  in  pregnancy,  256. 
Ptyalism,  413. 
Pilch  (nephritis),  455. 
Puerperium   and   digestive  functions, 

411. 


INDEX 


491 


Puerperium.     See  also  Child-bed. 
Pulmonary  diseases  of  rare  frequency, 

402. 
Pulmonary  and  laryngeal  tuberculosis, 

363- 

Pulmonary  disturbances  during  preg- 
nancy, 333. 

Pulmonary  stenosis,  325. 

Purpura  haemorrhagica,  310. 

Pyelitis,  467. 

Pyelonephritis,  467. 

Pyonephritis,  467. 

Q 

Quadroons,  185. 

Quetelet  (sterility,  etc.),  200. 

Quintroons,  185. 

R 

Race,  etc.,  127,  etc. 

Races,  coloured,  132,  etc. 

Races,  acclimatisation  of,  145. 

Races,  mixture  of,  149,  182. 

Raciborski  (bacteriorrhcea),  225. 

Ranke  (climate,  etc.),  135. 

Ranke  (marr.  age),  173. 

Ratzel  (marr.  age),  173. 

Ratzel  (promiscuous  marriages),  94. 

Rave  (haemophilia),  311. 

Raven  (fibrinous  bronchitis),  403. 

Reaction,  74. 

Rectocele  vaginalis,  428. 

Rectum,  prolapse  of,  428. 

Reed,  and  others  (yellow  fever),  159. 

Rees  (malaria),  155. 

Reibmayr  (tuberculosis  and  marriage), 

371,  387- 

Reibmayr  (in-and-in-breeding),  81. 

Remiss  (consang.  marr.),  99. 

Renal  calculi,  474. 

Renal  operations,  475. 

Respiratory  organs,  diseases  of,  in  re- 
lation to  marriage,  by  Kaminer,  363. 

Restriction  of  marriage,  13. 

Retina,  affections  of,  456. 

Retinitis  albuminurica  and  artificial 
abortion,  456. 

Ribbing  (continence),  228. 

Ribbing  (pessaries),  238. 

Ribbing  (sexual  hygiene,  etc.),  210, 
216,  219,  220,  221,  226,  242. 

Richl  (physiognomy),  181. 

Richter.     See  Loewy  and  Richter. 

Richter  (diseases  of  kidneys),  443. 

Riffel  (tuberculosis  and  marriage),  371. 

Riffel   (.transmission   of    tuberculosis), 

384- 

Riffel.     See  Reibmayr. 
Riviere  (infectiousness  of  tuberculosis), 

377- 

Roberts  (Dercum's  disease),  287. 
Rohleder  (condoms),  239. 


Rohleder  (continence),  228,  230. 
Rohleder  (interrupted  coitus),  235. 
Rohleder  (optional  sterility),  233. 
Rohleder  (pessaries),  238. 
Rohleder  (safety-spongelets),  237. 
Rohleder  (sexual  desire),  218. 
Rollet  (movable  kidney),  467. 
Rosenbach  (bradycardia),  354. 
Rosenbach  (tuberculosis),  366. 
Rosenfeld  (heart  disease),  327. 
Rosenstein  (tuberculous  changes),  380. 
Rosin   (blood   diseases   in    relation   to 

marriage),  295. 
Ross  (malaria),  155. 
Roszkiewicz  (menstr.),  172. 
Rousselet  (acclimatisation,  etc.),  150. 
Roux  (degeneration),  51. 
Rubner  (climate,  etc.),  131,  132,  138. 
Rubner  (sex.  interc.),  211. 
Rut,  218. 
Rut  and  menstruation,  278. 


Sachs  (consang.  marr.),  IOO. 

Safety-spongelets,  237. 

Salivation.     See  Ptyalism. 

Salter  (asthma),  398. 

Sambon  (malaria),  155. 

Sambos,  184. 

Sanchez-Toledo  (transmission  of  tuber- 
culosis), 383. 

Singer  (leukaemia),  317. 

Sanger  and  v.  Herff  (dyspepsia  of 
pregnancy),  419. 

Saniter  (pernic.  anaemia),  317. 

Scanzoni  (menstr.),  171. 

Schafer  (laceration  of  intestines),  421. 

Schauta  (nephritis),  457. 

Schauta  (prophylactic  abortion),  394. 

Scheer  (climate,  etc.),  139. 

Scheimpflug  (predisposition  to  tuber- 
culosis), 388. 

Schellong  (climate,  etc.),  131. 

Schellong  (endemic  diseases),  154,  166. 

Schenck  von  Grafenberg  (infectious- 
ness  of  tuberculosis),  377. 

Schenk  (fecundation  in  plants),  97. 

Scherbel  (consang.  marr.),  101. 

Scherzer  (abortion),  203. 

Scheube  (climate,  etc.),  131. 

Scheube  (distrib.  of  syphilis),  186. 

Schiel  (tubercle  bacillus),  381. 

Schiller-Titz  (consang.  marr.),  85,  86, 

94,  95,  96- 

Schilling  (consang.  marr.),  100. 
Schleyer  (premature    labour   in   heart 

disease),  340. 

Schmidt  (consang.  marr.),  101. 
Schmidt  (haemophilia),  311. 
Schmidt  (tuberculosis),  365. 
Schmitz  (diabetes),  271,  277. 
Schmorl  (tuberculous  changes),  380. 
Schneider  (laceration  of  intestines),  421. 


492 


INDEX 


Schonlein  (haemophilia),  311. 

Schramm  (marriage  after  nephrec- 
tomy),  475,  47°- 

Schrenk-Notzing  (continence),  229. 

Schrenk-Notzing  (sex.  interc.),  211. 

Schroder  (acute  yellow  atrophy  of 
liver),  431. 

Schroder  (leukaemia),  317. 

Schroter  (pelvis),  195. 

Schrotter  (phlebo-sclerosis),  356. 

Schrotter  (varix),  357. 

Schuchart  (tubercle  bacillus),  380. 

Schultze  (acclimatisation,  etc.),  151. 

Schwoner*(acromegaly),  289. 

Sclerodermia,  266. 

Scorbutus  (scurvy),  310. 

Scrofula,  289. 

Scrofula  and  tuberculosis,  290. 

Scrofula,  general  predisposition  to 
tuberculosis,  50. 

Scrofula,  nothing  but  tuberculous  proc- 
ess, 49. 

Scudamore  (gout),  280. 

Scurvy,  310. 

Seaumanoir  (syphilis),  187. 

See  (predisposition),  383. 

Seegen  (diabetes),  276. 

Semen,  re-absorption  of,  2O. 

Senator  (diabetes),  272,  274,  277. 

Senator  (constitutional  diseases  in  re- 
lation to  marriage),  265. 

Senator  (Introduction),  5. 

Senator  (movable  kidney),  467. 

Senator  (nephritis),  452,  461,  463. 

Sequin  (consang.  marr.),  99. 

Sexes,  numerical  proportion  of  both, 

175- 

Sexual  abstention.  See  also  Conti- 
nence, 228. 

Sexual  anaesthesia  in  women,  217. 

Sexual  excess,  results  of,  222. 

Sexual  function  and  obesity,  284. 

Sexual  function,  duration  of,  in  male 
sex,  172. 

Sexual  hygiene,  general  measures,  240. 

Sexual  hygiene  in  married  life,  by 
Furbringer,  209. 

Sexual  intercourse,  abnormal  position 
in,  and  disease,  214. 

Sexual  intercourse  and  asthma,  400. 

Sexual  intercourse  and  pregnancy,  257. 

Sexual  intercourse  during  child-bed, 
260. 

Sexual  intercourse  during  involution- 
period,  232. 

Sexual  intercourse  during  menstrua- 
tion, 223. 

Sexual  intercourse  during  pregnancy, 
225. 

Sexual  intercourse,  force  in,  219. 

Sexual  intercourse,  frequency  of,  219. 

Sexual  intercourse  in  heart  disease, 
350. 

Sexual  intercourse,  interrupted,  234. 


Sexual  intercourse,  necessity  of,  20. 

Sexual  intercourse,  non-connubial, 
condemned,  23. 

Sexual  intercourse /<rr  se  cause  of  dis- 
ease, 8. 

Sexual  intercourse,  position  in,  212, 
226. 

Sexual  intercourse,  preventive,  232. 

Sexual  intercourse,  regulation  and 
performance  of,  210. 

Sexual  intercourse,  regulation  of,  17. 

Sexual  intercourse,  suspension  of,  dur- 
ing menstruation,  246. 

Sexual  intercourse,  time  of,  216. 

Sexual  life  in  the  tropics,  142. 

Sexual  maturity,  169. 

Sexual  neurasthemia.  See  also  Neuras- 
thenia, 222. 

Sexual  trauma,  216. 

Shakespeare  quoted,  408. 

Shakespeare's  Imogen,  216. 

Silex  (pregnancy-retinitis),  456. 

Simpson  (arterio-sclerosis  and  labour), 
356. 

Simpson  (spleen),  434. 

Simpson  (heart  disease  and  labour), 
332. 

Sims  (pseudo-gonorrhoea),  225. 

Skrivaz  (hernia),  422. 

Solon  (frequency  of  sex.  interc.),  219. 

Soma  (opposed  to  germplasma),  44. 

Sommer  (artificial  epilepsy),  68. 

Soranus  of  Ephesus  quoted,  245. 

Spaeth  (acute  yellow  atrophy),  432. 

Spartan  customs,  6. 

Spermatic  impulse,  229. 

Spiegelberg  (premature  labour  in  heart 
disease),  340. 

Spiegelberg  (pulmonary  circulation 
and  pregnancy),  333. 

Splanchnoptosis,  419. 

Spleen,  disorders  of  the,  434. 

Splenoptosis,  419. 

Sporadic  cretinism,  287. 

Sputum  as  an  infecting  medium  in 
tuberculosis,  381. 

Stader  (nephritis),  454. 

Stahel  (haemophilia),  313. 

Statistics  (Boeckh),  24. 

Statistics  on  consanguinity,  104. 

Statistics  ( Wester gaard),  19,  24,  27. 

Steatopygia,  196. 

Stegomyia  fasciata  Theobald,  159. 

Sterility,  anthropological  observations 
on,  199. 

Sterility  due  to  reflux  of  semen,  213. 

Sterility,  resulting  from  consang.  mar- 
riages, 99. 

Stevens  (abortion),  203. 

Stille  (optional  sterility),  233. 

Stillmann  (leukaemia),  317. 

Stintzing  (continence),  230. 

Stohl  (tubercle  bacillus),  381. 

Stockvis  (acclimatisation,  etc.),  151. 


INDEX 


493 


Stockvis  (climate,  etc.),  139. 
Stomach,  diseases  of,  409. 
Stomatitis  (aphthous),  415. 
Strassmann    (tuberculosis    and    preg- 
nancy), 373. 
Stratz  (on  beauty),  181. 
Strobl  (acute  yellow  atrophy  of  liver), 

43i. 

Strubing  (Dercum's  disease),  287. 

Struthers  (case  of  polydactylism),  53. 

Students  and  venereal  disease,  228. 

Stumpf  (laceration  of  intestines),  421. 

Stumpf  (blood  diseases),  310. 

Successive  pregnancies,  effect  of,  on 
offspring,  27. 

Sudden  death  during  coitus,  352. 

Suicide  and  marriage,  22. 

Summary  on  heredity,  71. 

Sum  of  heredity,  84. 

Syncytolisin,  431. 

Syphilis  and  heart  disease,  348. 

Syphilis  and  gout,  281. 

Syphilis,  distribution  of,  186. 

Syphilis,  late  congenital,  45. 

Syphilis  of  parents,  effects  of,  on  off- 
spring, 28. 


Tachycardia,  346. 

Tachycardia,  paroxysmal,  354. 

Tacitus  (menstr.),  171. 

Talmud  (frequency  of  sex.  interc.  ac- 
cording to),  219. 

Tannhauser,  220. 

Tappeiner  (tubercle  bacillus),  381. 

Teissier  (diabetes),  272. 

Tendency  to  disease,  44. 

Terceroons,  185. 

Teschenmacher  (diabetes),  276. 

Therapeutic  abortion,  255. 

Theromorphism,  74. 

Thompson  (interrupted  coitus),  235. 

Thompson  (optional  sterility),  233. 

Thorn  (tuberculous  changes),  380. 

Thrombosis  in  puerperium,  357. 

Tight  clothes  and  sex.  interc.,  218. 

Tight-lacing  condemned,  33. 

Tilt  (menstr.),  170. 

Titillatio  clitoridis,  240. 

Tobacco.     See  Nicotine. 

Toothache  and  pregnancy,  411. 

Totem,  94. 

Toxicity  of  menstrual  blood,  247. 

Transformism,  75. 

Transmission  hereditary.  See  Heredi- 
tary transmission. 

Trauma,  sexual,  216. 

Treatment,  psychical,  of  impotence, 
242. 

Tredondani  (nephrectomy),  477. 

Tropical  climate,  effects  of,  130. 

Tropical  frenzy,  139. 

Tropics,  acclimatisation  in,  136. 


Tropics,  alcohol  in  the,  144. 

Tropics,  climate  of,  130,  143. 

Tropics,  hygiene  in,  144. 

Tropics,  marriage  in,  185. 

Tropics,  nutrition  in,  135. 

Tropics,  physiol.  processes  in,  136,  etc. 

Tropics,  requirement  of  water  in,  136. 

Tropics,  sexual  life  in,  142. 

Trousseau  (frequency  of  sex.  interc.), 
220. 

Tschich  (interrupted  coitus),  236. 

Tuberculin  test,  389. 

Tuberculosis  and  conjugal  inter- 
course), 391. 

Tuberculosis  and  heredity,  382. 

Tuberculosis  and  lactation,  376. 

Tuberculosis  and  marriage,  368,  369, 
387. 

Tuberculosis  and  the  offspring,  28, 
382. 

Tuberculosis  and  pregnancy,  372. 

Tuberculosis,  artificially  produced,  41. 

Tuberculosis,  distribution  of,  189. 

Tuberculosis,  hereditary  predisposi- 
tion to,  49. 

Tuberculosis  of  kidneys,  470. 

Tuberculosis  of  husband,  369. 

Tuberculosis  of  wife,  372. 

Tuberculosis  of  married  persons,  pro- 
phylaxis in,  392. 

Tuberculosis,  transmission  of,  through 
sexual  intercourse,  379. 

Tuberculosis,  predisposition  to,  383. 

Tuberculosis,  pulmonary  and  laryn- 
geal,  363. 

Tuberculosis,  transmission  of,  in  mar- 
ried life,  377. 

Tuke  (menstr.),  172. 

Tumours  of  kidney,  474. 

Tuszkai  (dyspepsia),  419. 

Typhus  and  heart  disease,  345. 

U 

Uffelmann  (endemic  diseases),  153. 
Untzenbrecher  (haemophilia),  314. 


Vagina,  laceration  of,  215. 

Vaginal  antiseptic  introductions  for 
preventing  conception,  237. 

Vaginal  hyperaesthesia,  216. 

Vaginal  irrigations  for  preventing  con- 
ception, 237. 

Vaginismus,  216. 

Van  t'  Hoff  (Grave's  disease),  347. 

Van  Ysendyk  (tuberculosis  and  preg- 
nancy), 373,  375. 

Van  Ysendyk  (tuberculosis  and  mar- 
riage), 368. 

Variococele,  358. 

Varicose  veins,  357. 

Varix,  357. 


494 


INDEX 


Varix,  essential,  358. 

Valenta  (interrupted  coitus),  236. 

Valvular  heart  disease,  acquired,  327. 

Van  Swieten,  240. 

Vascular  system,  diseases  of  the,  and 

marriage,  321. 
Vegetable    world,    crossing    and    self 

fecundation  in,  97. 
Veins,  dilatation  of,  357. 
Veins,  diseases  of  the,  356. 
Veil  (acute  yellow  atrophy  of  liver), 

43i. 

Venereal  disease  and  students,  228. 
Venereal  diseases,  prevention  of,  228. 
Vierordt  (heart  disease),  324,  325,  326. 
Vieti  (haemophilia),  313. 
Vinay  (pyelitis),  469. 
Virchow   (acclimatisation,    etc.),    145, 

153. 

Virchow  (descent  and  pathology),  385. 
Virchow  (haemophilia),  312. 
Virchow  (heart  disease),  326. 
Virchow  (heart  disease  and  child-bed), 

332. 
Virchow   (hereditary   transmission    of 

acquired  peculiarities),  59. 
Virchow  (heredity),  382. 
Virchow  (malaria),  155. 
Virchow  (marriage  and  tuberculosis), 

368. 
Virchow   (phthisis   and    tuberculosis), 

363- 
Virchow   (physiological    leucocytosis), 

251- 

Virchow  (promiscuous  marriages),  94. 
Virchow  (tuberculosis  and  marriage), 

391. 

Virility  in  men,  duration  of,  172,  222. 
Virility.     See  also  Sexual  function. 
Virility.     See  also  Potency. 
Vitruvius  quoted,  128. 
Vogt  (menstr.),  170. 
Voisin  (consang.  marr.),  96. 
Voit  (climate,  etc.),  135. 
Volckmann  (optional  sterility),  233. 
Voltolini  (asthma),  399. 
Vomiting  of  pregnancy,  415. 

W 

Wachsmut  (haemophilia),  313. 

Waitz  (consang.  marr.),  99. 

Waller  (tubercle  bacillus),  379. 

Wandering-spleen,  435. 

Warning  to  students  against  venereal 

disease,  228. 

Washbourn  (albuminuria),  448. 
Water,  requirement  of,  in  the  tropics, 

135- 

Webb  (abortion),  203. 
Weber  (pelvis),  194. 
Weber  (tuberculosis),  189. 
Weber  (tuberculosis  and   pregnancy), 

373- 


Weber  (tuberculosis,  infectiousness  of), 

377- 

Wecker  (consang.  marr.),  101. 

Wedding  day  and  menstruation,  248. 

Wehle  (haemophilia),  316. 

Weil  (diabetes  insip.),  279. 

Weinbaum  (nephritis),  455,  458,  460. 

Weise  (blood  diseases),  310. 

Weiss  (Dercum's  disease),  287. 

Weissl's  preservative,  238. 

Weissmann  (acclimatisation,  etc.),  145. 

Weissmann's  determinants,  60. 

Weissmann  (germ-plasma),  42. 

Weissmann  (soma),  44. 

Weissmann  (hered.  transm.  of  acquired 
peculiarities),  59. 

Wendt  (haemophilia),  315,  316. 

Werlhof's  purpura.  310. 

Wernich  (climate,  etc.),  132. 

Wernich  (menstruation),  172. 

Wessner  (heart  disease  and  preg- 
nancy), 330,  336,  340,  341. 

Westergaard  (statistics),  19,  24,  27. 

Westermayer  (tubercle  bacillus),  379. 

Westerode  (nephritis),  455. 

Westphal  (artificial  epilepsy),  68. 

White  (gastric  catarrh),  420. 

Wichmann  (case  of  laceration  of  va- 
gina), 215. 

Wiedersheim  (variations  in  germ- 
plasma),  60. 

Wiener  (blood  diseases),  310. 

Wife,  choice  of  a,  31. 

Wintrich  (effect  of  pregnancy  on  the 
lungs),  333. 

Wintrich  (pregnancy  and  tuberculosis), 

374- 
Wolff  (transmission  of    tuberculosis), 

383. 

Wolff.     See  Leyden  and  Wolff. 
Wolpert  (climate,  etc.),  132. 
Woman,  beauty  of,  180. 
Wulfert  (climate,  etc.),  141,  144. 


Xenophon  (Spartan  customs),  6. 


Yellow  fever,  158. 


Zeissl  (pseudo-gonorrhcea),  225,  227. 

Ziegler  (tubercle  bacillus),  379. 

Ziegler  (unsuitable  germ-cells),  62. 

Zimmermann  (haemophilia),  312. 

Zoroaster  (frequency  of  sex.  interc.), 
219. 

Zoth  and  Pregel  (Brown-Sequard's  ex- 
tract). 20. 

Zweifel  (pregnancy  and  heart  disease), 
329,  332. 


LIST  OF  AUTHORS  QUOTED  IN  VOL.  I. 


Acton,  221. 
Adler,  240. 
Adler,  O.,  217. 
Agramonte,  159. 
Agres,  101. 
Albert,  215. 
Ammann,  313. 
Ammon,  387. 
Andral,  372. 
Aristotle,  6,  7. 
Arrago,  96. 
Ashton,  418. 
Assmuth,  228. 
Audibert,  413. 

B 

Bacon,  38. 

Badjuri,  86. 

Baelz,  178. 

Bagnold,  131. 

Bailey,  99. 

Banti,  316. 

Bardeleben,  v.,  343. 

Bartels,  450. 

Barucco,  235,  236,  239. 

Bastian,  146. 

Bastian,  Adolf,  179. 

Baudin,  163. 

Baumes,  372. 

Beard,  221,  235,  239. 

Bebel,  229. 

Beck,  366. 

Bergeret,  236. 

Berkart,  398. 

Bertillon,  147,  148,  163. 

Bertz,  242. 

Binswanger,  223. 

Birch-Hirschfeld,3ii,379. 

Birmer,  316. 

Blessig,  228. 

Blot,  330. 

Bockhart,  225. 

Boeckh,  24. 

Bolsche,  99. 

Boismont,  Brierrede,  170. 

Bonardi,  E.,  289. 

Bordeau,  372. 

Bossi,  343,  430. 

Bouchard,  276,  280,  283. 

Boudin,  97,  99,  101,  102. 

Bourgeois,  99. 

Boye,  423,  425. 


Brauer,  430. 

Dickinson,  458. 

Brault,  467. 

Diday,  225. 

Braun,  280,  353,  464. 

Diehl,  311. 

Breuer,  216. 

Dietrich,  419. 

Breymann,  289. 

Dietrich,  A.,  76. 

Brocard,  267. 

Dieu,  173. 

Brown-Sequard,  68. 

Dittrich,  123. 

Bruggemann,  399. 

Dohm,  333. 

Buckle,  89. 

Dohrn,  340,  374. 

Biichner,  96. 

Donner,  218. 

Buhl,  433. 

Douglas,  432. 

Dubreuil,  372. 

C 

Ducrest,  330. 

Cameron,  96,  317. 

Duplay,  173. 

Camp,  de  la,  325,  326. 

During  Pasha,  v.     187. 

Carpentier,  458. 

Durosiez,  330. 

Carrall.  159. 

Dutrouleau,  163. 

Casper,  L.,  225,  229. 

Chamberlain,  93. 

E 

Chambers,  283. 

Edleffsen,  421. 

Charcot,  347. 

Eisenhardt,  413,  422. 

Charpentier,  433. 

Elberskirchen,  217. 

Chelius,  314. 

Ellinger,  376. 

Cohen,  G.,  316. 

Ellis,  224. 

Cohnheim,  383. 

Ellis,  Havelook,  218. 

Cohnstein,  417. 

Emin  Pasha,  144. 

Collen,  372. 

Erb,  219,  220. 

Collumella,  247. 

Esmarch-Kulenkamp,  v., 

Columbat,  196. 

56. 

Commandeur,  317. 

Eulenburg,  131,  220,  223, 

Condamin,  416. 

228,  233,  236,  241. 

Cordier,  181. 

Ewald,   C.   A.,   419,   421, 

Cornet,  377,  380,  381. 

426. 

Costa,  Da,  339. 

Exner,  J.,  20,  54. 

Cure,  415. 

Curschmann,  218,  219,  223, 

F 

228,  230. 

Fehling,  358,  454,  455,  458, 

Cutler,  100. 

464. 

Cyr,  434. 

Felkin,  164. 

Czempin,  373. 

Fellner,  270,  310,  316,  317, 

331,  332,  337,  344,  351, 

D 

403,  415,  417,  423,  424, 

Daremberg,  370. 

425,  431,  45i,  455,  460, 

Darwin,  67,  99,   123,   179, 

461,  462,  464,  468,  469. 

181,  184,  322. 

Ferdy,  239. 

Daubler,  131,  151,  343. 

F6re,  217,  287. 

Decandolle,  182. 

Fiebig,  145. 

Dechambre,  99. 

Fieux,  465. 

Delage,  74. 

Finger,  225. 

Delage  Yves,  76. 

Finke,  172. 

Depage,  469,  470. 

Finsch,  182. 

Deparcieux,  20. 

Fischer,  316,  381,  453. 

Devay,  99. 

Fischer-Dtickelmann,  211. 

496 


LIST   OF   AUTHORS 


Fison,  94. 

Flaischlen,  454,  455. 
Flourens,  183. 
Fluegge,  382. 
Fonsagrives,  163. 
Fordyce,  311. 
Forel,  228. 
Forster,  316. 
Fournier,  465. 
Fraenkel,    A.,    289,    373, 

375,  398,  399- 
Fraenkel,  424. 
Fraenkel,  E.,  226. 
Frank,  372,  430. 
Frank,  Peter,  377. 
Frerichs,  276. 
Freud,  216,  233,  236. 
Freund,  50,  358,  384. 
Freund,  H.  W.,  415. 
Freund,  A.,  417,  418,  427. 
Freund,  W.  A.,  426,  428, 

435- 

Freund,  Richard,  432. 
Freyhan,  454. 
Friedmann,  43,  45. 
Fritsch,  184,  185,  350. 
Flirbringer,  248,  249,  254, 

369,  409,  450. 

G 

Gaertner,  380,  383. 

Galen,  377. 

Galippe,  412. 

Galtier,  381. 

Gattel,  236. 

Gar  rod,  O.  B.,  280. 

Gegenbauer,  52. 

Gendre,  P.  Le,  76. 

Georg,  Damian,  201. 

Gerhardt,    330,    367,   368, 

369,  373,  376,  391,  393- 
Glogner,  133,  138. 
Gocht,  316. 
Goethe,  14. 
Goldscheider,  240. 
Golgi,  155. 
Gottstein,  384. 
Grafenberg,  v.,  377. 
Grandidier,  311,  312,  313, 

315. 

Green,  317. 
Gregory  I.,  Pope,  86. 
Griesinger,  158,  276. 
Grisolle,  372,  376. 
Gruber,  122,  276. 
Gusserow,  375,  396,  397. 
Gutierrez,  195. 
Guttzeit,  217. 
Gyurgovechky,    v.,     220, 

229,  235,  241. 


H 


Hack,  399. 
Hahn,  454. 


Haidlen,  429. 
Hamburger,  373,  375,  385, 

395- 

Hammond,  223. 
Hanau,  375. 
Hansemann,  215. 
Hartman,  173. 
Hartsen,  368. 
Hasse,  233. 
Hecker,  C.,  433. 
Hegar,  214,  227,  228,  229, 

231,  233. 
Helfft,  149,  163. 
Hellwig,  Prof.,  14. 
Henle,  134. 
Hensen,  171. 
Herff,  v.,  419. 
Herrlich,  455. 
Hertwig,  O.  and  R.,  63. 
Herzen,  228. 
Hilbert,  317. 
Hildebrandt,  427. 
Hirt,  236. 
Hirsch,  L.,  121. 
Hirsch,  128,  156,  162,  163, 

189. 

Hirschberg,  101. 
Hoerschelmann,  228. 
Hofmann,  339. 
Hofmeier,  454,  458,  461, 

464. 

Homer,  312. 
Hosli,  312,  316. 
HOsslin,  v.,  235. 
Houston  Chamberlain,  89. 
Howe,  99. 
Howitt,  94. 
Huchard,  353,  434. 
Htippe,  144. 
Huth,  96,  101. 

I 

Innocent  III.,  88. 

Isidor,  97. 

Israel,  469,  471,  472,  477. 

J 

Jablotschkoff,  G.,  277. 
Jacob,  240,  370,  373,  374, 
376,  378,  391- 

aggard,  317. 

ager,  101. 

ani,  379. 

arret,  456. 

aworsky,  v.,  317. 
Jeoffroy,  347. 
Joachim,  170. 
Jousset,  163. 

K 

Kaltenbach,  214,  416. 
Kaminer,  373. 
Kehrer,  315,  412,  413. 
Kidd,  311,  316. 


Kirchner,  368,  380,  385. 

Kirk,  412. 

Kisch,  236,  238,  283,  285, 

351- 

Kitasato,  161. 
Klebs,  433. 
Kleinwaechter,   225,    394, 

457- 

Klemperer,  240. 
Klunzinger,  175. 
Knapp,  467. 
Koblanck,  454,  455. 
Koch,  155,   156,  157,   160, 

161,  312,  316,  366,  367, 

383- 

KCgel,  172. 
Kohl,  99. 

Konig,  424,  425,  472,  476. 
Kossmann,  392. 
Kotscher,  218. 
Krafft-Ebing,   v.,   57,    64, 

65,   217,    224,   229,   235, 

236. 

Krascheninnikoff,  96. 
Krause,  134. 
Krieger,  170. 
Kroenig,  B.,  228. 
Krusemann,  95. 
Krzyminski,  455. 
Kiichenmeister,  333,  374. 
Killz,  271,  272,  273,  277. 
Kutiak,  422. 
Kuttner,  373,  395. 


Lallemand,  228. 
Lancereaux,  328. 
Landau,  L.,  420. 
Laqueur,  100. 
Larcher,  329,  330. 
Laveran,  155. 
Lavoisier,  138. 
Lazear,  159. 
Leber,  100,  121. 
Lecorch6,  280. 
Lennander,  357. 
Leo,  H.,  272. 
Leube,  448. 
Leudet,  372,  384. 
Leyden,  v.,  240,  329,  345, 

365,  369,  372,  373,  374, 

393,  396,  452,  455,  457, 

458,  460. 

Liebreich,  101,  102. 
Liguori,  Alfonse  of,  248, 

260. 

Lind,  Jacob,  143. 
Lingard,  58. 
Liszt,  Prof,  v.,  14. 
Litten,  316. 
Litzmann,  171,  19$. 
Livingstone,  189. 
Lode,  212. 
Loewy,  284. 


LIST   OF   AUTHORS 


497 


Lo'hlein,  330,  340,  415, 454, 

459,  460. 

Lohnberg,  373,  395. 
Lombroso,  75. 
Lomer,  431. 
Lorenz,  O.,  123. 
Lorenz,  83,  93,  99. 
Lossen,  311,  314,  315. 
Low,  155. 
Lowenfeld,  218,  220,  222, 

223,   228,  230,  233,  235, 

236,  239. 

Lubarsch,  40,  76. 
Lubbock,  178. 
Ludwig,  H.,  267. 
Lwoff,  413. 
Lycurgus,  173. 
Lyon,  225. 

M 
Macdonald,  330,  336,  337, 

338,  339- 

Magnus,  O.,  85,  101. 
Mahillon,  358. 
Mahly,  163. 
Main,  85. 
Malthus,  177. 
Manley,  422. 

Mantegazza,  99,   171,  220. 
Maragliano,  375,  385^  393, 

394,  395,  396. 
Marestang,  138. 
Marey,  331. 
Martin,  140,  194,  366. 
Marx,  425. 
Masing,  228. 
Massoin,  68. 
Matthieu,  467. 
Mayer,  Jos.,  228. 
Mayet,  104,  108,  109,  no, 

in,  112,   116,   117,   118, 

119,   121. 
Mayet,  P.,  123. 
Mayr,  G.,  102. 
McArthur,  425. 
Meinhold,  430. 
Meissner,  L.,  421. 
Mendel,  228. 
Mendelsohn,  350. 
Mense,  131,  187. 
Mericourt,  Leroy  de,  163. 
Meyer,  F.,  328. 
Michaelis,  328. 
Minkowski,  328. 
Mitchell,  99. 
Mobius,  346. 
Mohammed,  219. 
Moll,  229. 
Mondiere,  172. 
Moren,  101. 
Morgan,  85,  96. 
Moricke,  458. 
Moritz,  358. 
Moses,  87,  no. 


Miiller,  P.,  214,  422,  434. 
Munk,  376.  i 
Mynlieff,  453,  458,  459. 

N 

Naegeli,  365,  367,  380,  390. 
Naunyn,     268,     273,    277, 

327,  434- 
Niemeyer,  363. 
Noorden,  von,  277,  283. 
Nothnagel,  210,  273. 

O 

Obersteiner,  69. 
Oefele,  von,  233. 
Oertel,  312. 
Olshausen,  216. 
Oppenheim,  175,  235. 
Oppler,  B.,  271,  272. 
Orschansky,  72,  75,  76. 
Orth,  61,  80,  383,  387. 
Oser,  429. 


Pannwitz,    370,   373,    374, 

A37°,  378,  391- 
Patissier,  280, 
Pawlinoff,  459. 
Peacock,  325,  330. 
Peipers,  84,    93,    99,    101, 

103,  104,  123. 
Perier,  99. 
Peschl,  173. 
Peters,  327. 
Peyer,  236,  400. 
Phillips,  310. 
Plato,  6,  7,  9,  14,  173. 
Plehn,  136,  138,  157,  166. 
Plinius,  128,  247. 
Ploss-Bartels,     173,    180, 

181,  193,   197,  200,  205, 

212,  215,   224,  227,  234, 

240,  247. 
Ponfick,  331. 
Portal,  372. 
Posner,  380. 
Pregel,  20. 
Prinzing,  24. 
Puech,  455. 

Q 

Quatrefages,  de,  163,  164. 
Quetelet,  200. 

R 

Raciborski,  225. 
Ranke,  W.  E.,  135. 
Ranke,  Johannes,  173. 
Ratzel,  94,  173. 
Rave,  311. 
Raven,  v.,  403. 
Reed,  159. 
Rees,  155. 


Reibmayr,  81,  89,  90,  92, 
123,  371,  387,  388. 

Remiss,  99. 

Reyher,  B.,  210,  211. 

Ribbert,  123. 

Ribbing,  210,  211,  216, 
219,  220,  221,  226,  228, 
238,  242. 

Ribot,  123. 

Richter,  284. 

Riehl,  181. 

Riffel,  371,  384,  385,  387. 

Riviere,  Lazare,  377. 

Roberts,  287. 

Rochard,  163. 

Rochebrune,  de,  202. 

Rockwell,  221. 

Rohde,  F.,  76. 

Rohleder.228,233,238,  239. 

Rollet,  467. 

Rosenbach,  354,  366. 

Rosenfeld,  327. 

Rosenstein,  380. 

Roskiewicz,  172. 

Ross,  155. 

Roth,  E.,  76. 

Rousselet,  150. 

Roux,'  51. 

Rover,  163. 

Rubner,  131,  132,  138. 

Ruge,  S.  Reinhold,  154. 


Sachs,  100. 
Salter,  398. 
Sambon,  155. 
Sanchez,  Toledo,  383. 
Sanger,  317,  419. 
Saniter,  317. 
Schafer,  421. 
Scanzoni,  171. 
Schauta,    394,    455,    457, 

460,  464. 

Scheer,  v.  d.,  139. 
Scheimpflug,  388. 
Schenk,  A.,  97. 
Schenk,  123. 
Schellong,  131,  154,  166. 
Scherbel,  roi,  123. 
Scherzer,  203. 
Scheube,  131,  186. 
Schiel,  381. 
Schiller-Titz,    85,    86,   94, 

95,  96,  123. 
Schleyer,  340. 
Schmidt,  101. 
Schmidt,  Alex.,  311. 
Schmidt,  Adolph,  365. 
Schmitz,  277. 
Schmitz,  R.,  271. 
Schmorl,  380. 
Schneider,  421. 
Schonlein,  311. 
Schramm,  475,  476. 


498 


LIST   OF   AUTHORS 


Schrenck- Notzing,      211, 

229. 

Schroeder,  431. 
Schroeder,  H.,  317. 
Schroeter,  195. 
Schro'tter,  v.,  356,  357. 
Schuchart,  357,  380. 
Schultze,  151. 
Schwalbe,  D.,  76. 
Schwoner,  S.  J.,  289. 
Scudamore,  Ch.  S.,  280. 
Seaumanoir,  187. 
S6e,  383. 
Seegen,  276. 
Senator,  274,  363.  373,  444, 

452,  461,  462,  463,  464, 

467. 

Sequin,  99. 
Shakespeare,  408. 
Silex,  456. 
Simpson,  T.  Y.,  332,  356, 

434- 

Sims,  225. 
Skrivaz,  422. 
Solon,  219. 
Sommer,  69. 
Soranus,  245. 
Spaeth,  432. 
Spiegelberg,  333,  340. 
Stahel,  313. 
Stevens,  203. 
Stieder,  105. 
Stille,  233. 
Stilling,  zoo. 
Stillmann,  317. 
Stintzing,  230. 
Stohl,  381. 
Stokvis,  139,  151,  152,  163, 

164. 

Strassmann,  373. 
Stratz,  181. 
Strobl,  431. 
Strubing,  287. 
Struthers,  53. 
Studer,  454. 
Stumpf,  310,  421. 
Swieten,  van,  240. 


Tacitus,  171. 
Tappeiner,  381. 
Teissier,  272,  273. 
Teschenmacher,  276. 
Thompson,  233,  235. 
Thorn,  380. 
Tilt,  170. 
Timaeus,  6. 
Tredondani,  477. 
Treille.  163. 
Trousseau,  220. 
Tschich,  v.,  236. 
Tuke,  172. 
Tuszkai,  419. 

U 

Uffelmann,  153. 
Untzenbrecher,  314. 


Vaillant,  le,  184. 

Valenta,  236. 

Van  t'  Hoff,  347. 

Veil,  431. 

Vieli,  312. 

Vierordt,  324,  326. 

Vinay,  469. 

Virchow,  59,  94,  145,  153, 
155,  163,  251,  312,  326, 
332,  363,  368,  380,  382, 

385,  39i- 
Vitruvius,  128. 
Vogt,  170. 
Voisin,  A.,  96. 
Voisin,  123. 
Voit,  135. 

Volkmann,  141,  233,  424. 
Voltolini,  399. 

W 

Wachsmut,  312. 
Waitz,  99. 
Walter,  379 
Washbourn,  448. 
Wassermann,  76. 


Weadt,  316. 
Webb,  Allan,  203. 
Weber,  194,  373,  377. 
Weber,  Herm.,  189. 
Wecker,  v.,  101. 
Wehle,  316. 
Weigert,  379. 
Weil,  A.,  279. 
Weinbaum,  455,  458,  460. 
Weise,  316. 
Weiss,  A.,  287. 
Weissmann,  42,  44,  59,  60, 

80,  145. 
Wendt,  315. 
Wernich,  132,  172. 
Wessner,    330,    340,    341, 

361, 
Westergaard,    19,   24,   25, 

27. 

Westermayer,  379. 
Westerode,  455. 
Westphal,  68. 
Weyl,  31. 
White,  420. 
Wichmann,  215,  235. 
Wiedersheim,  60. 
Wiener.  310. 
Wintrich,  333,  374. 
Wolff,  370,  373. 
Wolpert,  132,  383. 
Wulffert,  141,  144. 

X 

Xenophon,  6. 


Yersin,  161. 

Ysendyk,  368,  373,  375. 


Zeissel,  v.,  225,  227. 
Ziegler,  62,  379. 
Ziemssen,  218. 
Zimmermann,  312. 
Zoroaster,  219. 
Zoth,  20. 
Zweifel,  329,  332. 


